DSM v Audio Crash Course - Complete Review of the Diagnostic & Statistical Manual of Mental Disorder by AudioLearn

Diagnostic and Statistical Manual Fifth Edition Audio Crash Course™

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TABLE OF CONTENTS PREFACE .................................................................................................................................. 1 CHAPTER ONE: NEURODEVELOPMENTAL DISORDERS .............................................................. 7 Intellectual Disabilities .............................................................................................................. 7 Intellectual Disability (Intellectual Developmental Disorder) .................................................. 7 Global Developmental Delay .................................................................................................... 8 Communication Disorders ........................................................................................................ 9 Language Disorder .................................................................................................................. 10 Speech Sound Disorder (previously Phonological Disorder or 315.39) .................................. 11 Childhood-Onset Fluency Disorder (Stuttering) (315.35) ....................................................... 12 Social (Pragmatic) Communication Disorder .......................................................................... 13 Autism Spectrum Disorder (299.0) ......................................................................................... 15 Attention Deficit Hyperactivity Disorder (314.0X) .................................................................. 17 Specific Learning Disorders (315) ........................................................................................... 19 Motor Disorders ...................................................................................................................... 20 Developmental Coordination Disorder (314.5) ...................................................................... 20 Stereotypic Movement Disorder (307.3) ................................................................................ 22 Provisional Tic Disorder (307.21) ............................................................................................ 23 Tourette’s Disorder (307.23) .................................................................................................. 23 Persistent (Chronic) Motor or Vocal Tic Disorder ................................................................... 25 Key Takeaways ........................................................................................................................ 26 Quiz ......................................................................................................................................... 27

CHAPTER TWO: SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS ................ 31 Schizotypal Personality Disorder (301) ................................................................................... 31 Delusional Disorder (297.1) .................................................................................................... 32 Brief Psychotic Disorder (298.8) ............................................................................................. 35 Schizophreniform Disorder (295.40) ...................................................................................... 36 Schizophrenia (259.90) ........................................................................................................... 37 Schizoaffective Disorder (295.70) ........................................................................................... 39 Substance or Medication-induced Psychosis (292.9) ............................................................. 39 Psychotic Disorder due to a Medical Condition ..................................................................... 41 Catatonia (Multiple DSM-V Codes) ......................................................................................... 41 Key Takeaways ........................................................................................................................ 42 Quiz ......................................................................................................................................... 43 CHAPTER THREE: BIPOLAR AND RELATED DISORDERS ........................................................... 47 Bipolar I Disorder (296) ........................................................................................................... 47 Bipolar II Disorder (296.89) ..................................................................................................... 50 Cyclothymic Disorder (301.13) ............................................................................................... 51 Medication or Substance-induced Bipolar Disorder............................................................... 52 Key Takeaways ........................................................................................................................ 54 Quiz ......................................................................................................................................... 55 CHAPTER FOUR: DEPRESSIVE DISORDERS .............................................................................. 59 Disruptive Mood Dysregulation Disorder (296.99)................................................................. 59 Major Depressive Disorder (296.20-296.36) .......................................................................... 60 Dysthymia (300.4) ................................................................................................................... 62 Premenstrual Dysphoric Disorder (625.4) .............................................................................. 64 Substance or Medication-induced Depressive Disorder ........................................................ 66 Depressive Disorder due to a Medical Condition (293.83)..................................................... 67 Key Takeaways ........................................................................................................................ 69

Quiz ......................................................................................................................................... 70 CHAPTER FIVE: ANXIETY DISORDERS ..................................................................................... 75 Separation Anxiety Disorder (309.21) .................................................................................... 75 Selective Mutism (312.23) ...................................................................................................... 77 Specific Phobia (300.29).......................................................................................................... 78 Social Anxiety Disorder (300.23) ............................................................................................. 80 Panic Disorder (300.01)........................................................................................................... 81 Specified Panic Attack ............................................................................................................. 82 Generalized Anxiety Disorder (300.02) ................................................................................... 84 Agoraphobia (300.22) ............................................................................................................. 85 Substance/medication-Induced Anxiety Disorder (292.8) ..................................................... 87 Anxiety due to a Medical Condition (293.84) ......................................................................... 88 Key Takeaways ........................................................................................................................ 89 CHAPTER SIX: OBSESSIVE COMPULSIVE AND RELATED DISORDERS........................................ 95 Obsessive compulsive Disorder (300.3) .................................................................................. 95 Body Dysmorphic Disorder (300.7) ......................................................................................... 96 Hoarding Disorder (300.3) ...................................................................................................... 99 Trichotillomania (312.39)...................................................................................................... 100 Excoriation Disorder (698.4) ................................................................................................. 103 Substance/Medication-Induced Obsessive-Compulsive and Related Disorder ................... 104 Obsessive-Compulsive and Related Disorder Due to Another Medical Condition .............. 105 Key Takeaways ...................................................................................................................... 106 Quiz ....................................................................................................................................... 107 CHAPTER SEVEN: TRAUMA AND STRESSOR-RELATED DISORDERS ....................................... 111 Reactive Attachment Disorder (313.89) ............................................................................... 111 Disinhibited Social Engagement Disorder (313.89) .............................................................. 112

Posttraumatic Stress Disorder (309.81) ................................................................................ 114 Acute Stress Disorder (308.3) ............................................................................................... 116 Adjustment Disorders ........................................................................................................... 117 Other Specified Trauma- and Stressor-Related Disorder (309.89) ....................................... 118 Key Takeaways ...................................................................................................................... 120 Quiz ....................................................................................................................................... 121 CHAPTER EIGHT: DISSOCIATIVE DISORDERS......................................................................... 125 Dissociative Identity Disorder (300.14) ................................................................................ 125 Dissociative Amnesia (300.12) .............................................................................................. 127 Depersonalization/Derealization Disorder (300.6) ............................................................... 129 Other Specified Dissociative Disorder (300.15) .................................................................... 131 Key Takeaways ...................................................................................................................... 132 Quiz ....................................................................................................................................... 133 CHAPTER NINE: SOMATIC SYMPTOMS AND RELATED DISORDERS ....................................... 137 Somatic Symptom Disorder (300.82) .................................................................................... 137 Illness Anxiety Disorder (300.7) ............................................................................................ 139 Conversion Disorder (Functional Neurological Symptom Disorder) (300.11) ...................... 141 Psychological Factors Affecting Other Medical Conditions (316)......................................... 142 Factitious Disorder (300.19) ................................................................................................. 143 Key Takeaways ...................................................................................................................... 145 CHAPTER TEN: FEEDING AND EATING DISORDERS ............................................................... 151 Pica (307.52) ......................................................................................................................... 151 Rumination Disorder (307.53) .............................................................................................. 153 Avoidant/Restrictive Food Intake Disorder (307.59) ............................................................ 154 Anorexia Nervosa (307.1) ..................................................................................................... 155 Bulimia Nervosa (307.51)...................................................................................................... 157

Binge-Eating Disorder (307.51) ............................................................................................. 159 Other Specified Feeding or Eating Disorder (307.59) ........................................................... 160 Key Takeaways ...................................................................................................................... 162 Quiz ....................................................................................................................................... 163 CHAPTER ELEVEN: ELIMINATION DISORDERS....................................................................... 167 Enuresis (307.6) .................................................................................................................... 167 Encopresis (307.7) ................................................................................................................. 169 Other Specified Elimination Disorder (787.60 or 788.39) .................................................... 170 Key Takeaways ...................................................................................................................... 172 Quiz ....................................................................................................................................... 173 CHAPTER TWELVE: SLEEP WAKE DISORDERS ....................................................................... 177 Insomnia Disorder (780.52) .................................................................................................. 177 Hypersomnolence Disorder (780.54) .................................................................................... 179 Narcolepsy (347.00) .............................................................................................................. 181 Breathing-Related Sleep Disorders ....................................................................................... 182 Obstructive Sleep Apnea Hypopnea (327.23)....................................................................... 182 Central Sleep Apnea .............................................................................................................. 183 Sleep-Related Hypoventilation (327.24) ............................................................................... 183 Parasomnias .......................................................................................................................... 184 Circadian Rhythm Sleep-Wake Disorders ............................................................................. 184 Non–Rapid Eye Movement Sleep Arousal Disorders............................................................ 185 Sleepwalking (307.46) ........................................................................................................... 186 Sleep Terrors (307.46) .......................................................................................................... 187 Nightmare Disorder (307.47) ................................................................................................ 188 Rapid Eye Movement Sleep Behavior Disorder (327.42) ..................................................... 189 Restless Legs Syndrome (333.94) ......................................................................................... 190 Substance/Medication-Induced Sleep Disorder ................................................................... 191

Other Specified Insomnia Disorder (780.52) ........................................................................ 191 Unspecified Insomnia Disorder (780.52) .............................................................................. 192 Other Specified Hypersomnolence Disorder (780.54).......................................................... 192 Key Takeaways ...................................................................................................................... 193 Quiz ....................................................................................................................................... 194 CHAPTER THIRTEEN: SEXUAL DISORDERS ............................................................................ 199 Delayed Ejaculation (302.74) ................................................................................................ 199 Erectile Disorder (302.72) ..................................................................................................... 200 Female Orgasmic Disorder (302.73) ..................................................................................... 201 Female Sexual Interest/Arousal Disorder (302.72) .............................................................. 202 Genito-Pelvic Pain/Penetration Disorder (302.76) ............................................................... 202 Male Hypoactive Sexual Desire Disorder (302.71) ............................................................... 203 Premature (Early) Ejaculation (302.75)................................................................................. 204 Substance/Medication-Induced Sexual Dysfunction (Various Codes) ................................. 205 Gender Dysphoria (302.85) ................................................................................................... 205 Key Takeaways ...................................................................................................................... 208 Quiz ....................................................................................................................................... 209 CHAPTER FOURTEEN: DISRUPTIVE, IMPULSE CONTROL, AND CONDUCT DISORDERS ........... 213 Oppositional Defiant Disorder (313.81)................................................................................ 213 Intermittent Explosive Disorder (312.34) ............................................................................. 214 Conduct Disorder (312.81) .................................................................................................... 215 Antisocial Personality Disorder (301.7) ................................................................................ 217 Pyromania (312.33) ............................................................................................................... 219 Kleptomania (312.32) ........................................................................................................... 220 Other Specified Disruptive, Impulse-Control, and Conduct Disorder (312.89) .................... 221 Key Takeaways ...................................................................................................................... 222 Quiz ....................................................................................................................................... 223

CHAPTER FIFTEEN: SUBSTANCE ABUSE AND RELATED DISORDERS....................................... 227 Substance-Related Disorders ................................................................................................ 227 Alcohol-Related Disorders .................................................................................................... 227 Caffeine-Related Disorders ................................................................................................... 229 Cannabis-Related Disorders .................................................................................................. 231 Hallucinogen-Related Disorders ........................................................................................... 233 Inhalant-Related Disorders ................................................................................................... 234 Sedative-, Hypnotic-, or Anxiolytic-Related Disorders ......................................................... 235 Stimulant-Related Disorders ................................................................................................. 237 Tobacco-Related Disorders ................................................................................................... 237 Non-Substance-Related Disorders ........................................................................................ 239 Gambling Disorder (312.31) .................................................................................................. 239 Key Takeaways ...................................................................................................................... 241 Quiz ....................................................................................................................................... 242 CHAPTER SIXTEEN: NEUROCOGNITIVE DISORDERS .............................................................. 247 Delirium (293.0) .................................................................................................................... 247 Major Neurocognitive Disorder (294.X)................................................................................ 249 Mild Neurocognitive Disorder (331.83) ................................................................................ 250 Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease .................................. 251 Major or Mild Frontotemporal Neurocognitive Disorder with Frontotemporal Disease .... 252 Major or Mild Neurocognitive Disorder with Lewy Bodies .................................................. 253 Major or Mild Vascular Neurocognitive Disorder ................................................................. 253 Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury............................... 254 Substance/Medication-Induced Major or Mild Neurocognitive Disorder ........................... 255 Major or Mild Neurocognitive Disorder Due to HIV Infection.............................................. 255 Major or Mild Neurocognitive Disorder Due to Prion Disease ............................................. 256 Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease ................................... 256 Major or Mild Neurocognitive Disorder Due to Huntington’s Disease ................................ 257

Major or Mild Neurocognitive Disorder Due to Multiple Etiologies .................................... 257 Unspecified Neurocognitive Disorder (799.59) .................................................................... 258 Key Takeaways ...................................................................................................................... 259 Quiz ....................................................................................................................................... 260 CHAPTER SEVENTEEN: PERSONALITY DISORDERS ................................................................ 265 Cluster A Personality Disorders ............................................................................................ 265 Paranoid Personality Disorder (301.0) .................................................................................. 265 Schizoid Personality Disorder (301.20) ................................................................................. 267 Schizotypal Personality Disorder (301.22) ............................................................................ 268 Cluster B Personality Disorders............................................................................................. 269 Antisocial Personality Disorder (301.7) ................................................................................ 269 Borderline Personality Disorder (301.83) ............................................................................. 270 Histrionic Personality Disorder (301.50) ............................................................................... 271 Narcissistic Personality Disorder (301.81) ............................................................................ 272 Cluster C Personality Disorders............................................................................................. 273 Avoidant Personality Disorder (301.82)................................................................................ 274 Dependent Personality Disorder (301.6) .............................................................................. 275 Obsessive-Compulsive Personality Disorder (301.4) ............................................................ 276 Key Takeaways ...................................................................................................................... 278 Quiz ....................................................................................................................................... 279 CHAPTER EIGHTEEN: PARAPHILIC DISORDERS ..................................................................... 283 Voyeuristic Disorder (302.82) ............................................................................................... 283 Exhibitionistic Disorder (302.4)............................................................................................. 284 Frotteuristic Disorder (302.89) ............................................................................................. 285 Sexual Masochism Disorder (302.83) ................................................................................... 286 Sexual Sadism Disorder (302.84) .......................................................................................... 287 Pedophilic Disorder (302.2) .................................................................................................. 288

Fetishistic Disorder (302.81) ................................................................................................. 289 Transvestic Disorder (302.3) ................................................................................................. 290 Key Takeaways ...................................................................................................................... 292 Quiz ....................................................................................................................................... 293 CHAPTER NINETEEN: MEDICATION-INDUCED MOVEMENT DISORDERS (DIMD) ................... 297 Types of Movement Disorders.............................................................................................. 297 Pathophysiology and Diagnosis of DIMD .............................................................................. 299 Treatment of DIMD ............................................................................................................... 299 Medication-induced Akathisia (333.99)................................................................................ 300 Medication-induced Acute Dystonia (333.72) ...................................................................... 300 Key Takeaways ...................................................................................................................... 301 Quiz ....................................................................................................................................... 302 SUMMARY ........................................................................................................................... 307 COURSE QUESTIONS AND ANSWERS ................................................................................... 313

PREFACE This course will attempt to unlock some of the rigidity of the Diagnostic and Statistical Manual, Fifth Edition or “DSM-V.” The DSM-V is a lengthy manual that reads like a dictionary of mental health terms, designed to make the abstract concepts of mental illness and categorize them. This is partly so that mental health workers can understand what the patient is suffering from in specific ways and partly to satisfy insurance and regulatory issues. There are around a hundred different categorized mental disorders in the DSM-V. Several of them state “other specified” mental health disorders that are covered as much as possible in this course. They usually involve a combination of other mental disorders but don’t fit neatly in any one category. Others will state “unspecified” mental health disorders, which will be less commonly covered in this course. These can mean just about anything that broadly fits into one of the larger categories. These are “catchall” categories that are difficult to clearly discuss. All other specified mental illnesses are covered in the chapters of this course. The subject of chapter one is neurodevelopmental disorders. These are usually diagnosed in infancy or childhood. They include various intellectual disabilities, communication disorders such as stuttering or language delays, autism spectrum disorders, ADHD, learning disorders and movement disorders (such as tics). While these are widely differing disorders, they are all associated with some abnormality in a child’s neural circuitry. Chapter two focuses on psychotic disorders and those that resemble schizophrenia. They range from the very short duration of brief psychotic disorder to the lifelong personality disorder called schizotypal personality disorder. Each of these will have characteristic psychotic features as a main component of the disorder but will differ in overall symptomatology and illness length.

Chapter three covers disorders that fall under the umbrella-term of “bipolar disorders.” These are related mood disorders that are characterized by extreme fluctuations in mood. By definition, these patients will have at least one manic episode as seen by an elevation in mood. Some patients will have a reduction in mood when not truly manic. A select few will have rapid-cycling disease with frequent fluctuations in mood. Chapter four examines the different depressive disorders. It primarily includes major depressive disorder and dysthymia but also includes less commonly seen disorders, such as premenstrual dysphoric disorder and disruptive mood dysregulation disorder. As with many psychiatric classifications within the DSM-IV, there is discussion of substance or medicationinduced depressive disorder and depression due to a medical condition. Anxiety disorders are the topic of chapter five. There are many mental illnesses that fall under this category. Some primarily affect children, such as separation anxiety. Some are very specific, such as specific phobia, agoraphobia, and social anxiety disorder. Others have no obvious focus, including panic disorder and generalized anxiety disorder. These and anxiety disorders caused by substances and medical conditions are covered in detail in this chapter. Chapter six discusses obsessive compulsive disorder (OCD) and related disorders. The related disorders have a wide range of symptoms and causes. They include things like body dysmorphic disorder, hoarding disorder, excoriation disorder, and trichotillomania. There are categories for OCD that is related to substance use and to a medical condition. Chapter seven focuses on the phenomenon of trauma and on trauma and stressor-related disorders. The most well-known example is post-traumatic stress disorder; however, there are many other trauma and stress-related disorders. These include reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders. There is also a category called other specified trauma and stressor-related disorder, which includes any disorder that has mixed features that don’t fit into any other specific category. Dissociative disorders are the topic of chapter eight. These are unique disorders that sometimes have their basis in trauma but can be stress-induced. The DSM-V has listed four 2

different dissociative disorders. The most well-known is dissociative identity disorder, formerly known as “multiple personality disorder.” Other dissociative disorders include dissociative amnesia, depersonalization/derealization disorder, and other specified dissociative disorder, which carries features of several of the other known dissociative disorders. The topic of chapter nine in the course is the different somatic disorders, beginning with somatic symptom disorder. There are several different somatic disorders with psychological origins or features that are recognized by the DSM-V as distinct entities. These include illness anxiety disorder, conversion disorder, and factitious disorder. There is a category for “psychological factors affecting other medical conditions,” which involves the different psychological states that influence the outcome of physical disorders. The major topic of chapter ten is feeding and eating disorders. This is a new category in the DSM-V and includes disorders like rumination disorder and pica in order to have an improved method of evaluating and treating eating-related disorders. The typical eating disorders, anorexia nervosa, bulimia, and binge-eating disorders remain as part of this classification. A newer sub-classification of other specified feeding and eating disorder has been added to identify individuals who do not fit neatly in any other category. The focus of chapter eleven in the course is elimination disorders. The DSM-V recognizes only three elimination disorders, including enuresis, encopresis, and other specified elimination disorder. These tend to occur in children but can also occur in older people as well, especially if they have developmental disabilities. There can be physical, neurological, and psychiatric reasons behind having an elimination disorder, which will be discussed in this chapter. Sleep-wake disorders are discussed in chapter twelve. They include a variety of sleep-related medical and psychological disorders affecting adults and children. The most common disorder is insomnia disorder; however, there are people with hypersomnolence disorder, narcolepsy, and breathing-related sleep disorders like sleep apnea. There are a number of disorders classified as parasomnias, including nightmare disorder, sleep terrors, and sleepwalking. Restless legs syndrome is also listed in the DSM-V as a sleep-wake disorder.

Chapter thirteen is about sexual disorders, which include those related to otherwise normal human sexuality. Men may have erectile disorder, delayed ejaculation, hypoactive sexual desire disorder, and premature ejaculation, while women can have female orgasmic disorder, female arousal disorder, and genito-pelvic pain/penetration disorder. Both men and women can have gender dysphoria or sexual dysfunction related to the use of a substance or substances. The main topic of chapter fourteen is disruptive, impulse control, and conduct disorders, which can affect children, adolescents, and adults. These include oppositional defiant disorder, intermittent explosive disorder, conduct disorder, and antisocial personality disorder. Also mentioned in this classification of DSM-V disorders are pyromania and kleptomania. The DSMV includes, in addition, a special category for other specified disruptive, impulse control, and conduct disorders. Chapter fifteen is about the DSM-V category of substance abuse and related disorders. It includes a variety of substances of abuse and their complications. Each has unique features that separate it from other substance abuse disorders and has different types of people at risk for the disorder. In addition, gambling disorder is included as a “related disorder” as it shares similar features to substance use disorders. Chapter sixteen in the course covers neurocognitive disorders, such as delirium and dementia. Both of these can cause mild, moderate, or severe cognitive deficits, which can be transient (as in delirium) or lifelong (as in most types of dementia). The DSM-V recognizes that there are major and mild neurocognitive disorders. There are different diagnoses for major or mild neurocognitive disorders with multiple different etiologies listed by the DSM-V. The topic of chapter seventeen is personality disorders. These are mental disorders defined as having a rigid and enduring pattern of thinking, behaving, and functioning that is considered out of the norm and that causes difficulty with the patient’s levels of functioning in work, school, relationships, and social activities. The individual is so tuned into their behavior and thinking that they often blame others for their difficulties and don’t recognize themselves as

having a disorder. The symptoms often begin in the teens or in early adulthood. There are three major clusters of personality disorders. Chapter eighteen discusses paraphilias or paraphilic disorders. These are a collection of related disorders that involve sexual deviancy. Individuals with a paraphilic disorder have a specific urge to engage in sexually-related behaviors that are considered out of the norm for modern society. They include things like voyeurism, transvestism, fetishism, frotteuristic disorder, and both sexual sadism and sexual masochism. People with these disorders are intensely aroused by things that most people are not aroused by. The subject of chapter nineteen in the course was added to the DSM-V because of the relatively high prevalence of movement disorders as a result of a wide variety of drugs that can cause medication-induced movement disorders. The classic drug classification considered causative of most movement disorders is that of dopamine blockers used in the treatment of psychotic disorders. There is medication-induced akathisia and acute dystonia, which come from using these medications.

CHAPTER ONE: NEURODEVELOPMENTAL DISORDERS Neurodevelopmental disorders are usually diagnosed in childhood and can be diagnosed in infancy. They include various intellectual disabilities, communication disorders such as stuttering or language delays, autism spectrum disorders, ADHD, learning disorders and movement disorders (such as tics). While these are widely differing disorders, they are all associated with some abnormality in a child’s neural circuitry.

INTELLECTUAL DISABILITIES An intellectual disability is an illness characterized by deficits in intellectual functioning and adaptive behavior (which entails skills necessary in social situations and practical life settings). It is a disorder of children under the age of 18 years of age. Some people use the term “mental retardation” to describe these children; however, intellectual disability is the preferred term. An intellectual disability is part of the term “developmental disability” but does not involve larger issues like seizure disorders, physical disabilities, and cerebral palsy. It is a complex disorder that takes more than just an IQ test to determine. The three major criteria are 1) onset before the age of 18 years; 2) limitations in intellectual functioning; and 3) limitations in adaptive behavior.

INTELLECTUAL DISABILITY (INTELLECTUAL DEVELOPMENTAL DISORDER) The DSM-V labels all disorders with a number. Intellectual developmental disorder is 319. As mentioned, there are three criteria that must be met. The first criterion, called Criterion A, is “deficits in intellectual functions, such as problem-solving, reasoning, judgment, abstract thinking, and academic learning.” This can be determined by standardized testing and/or

clinical assessment. This is usually tested with a culturally-appropriate, individuallyadministered, and psychometrically-sound series of tests of intelligence. Being more than 2 standard deviations below the mean indicate some degree of intellectual disability. Criterion B involves deficits in adaptive functioning or a failure to meet sociocultural or developmental standards for personal independence and social responsibility. Without ongoing social support, these adaptive deficits will limit the individual’s functioning in at least one area of daily life, such as social participation, communication, and ability to maintain independent living across multiple areas of the individual’s life, such as school, home, and recreational activities. It takes a clinical evaluation and individualized testing with reliable informants and the individual’s own assessment. The disorder also involves criterion C, which is that the onset of the disease needs to happen during the developmental period. This basically means prior to the age of 18 years, although it can usually be evident by the time the child reaches school age. There are specifiers as to the severity level of the disorder. It can be mild (in the range of IQ 5570); moderate (in the range of IQ 40-55); severe (in the range of IQ 25-40); or profound (with an IQ of less than 25). Remember that IQ scores alone are not diagnostic of the disorder.

GLOBAL DEVELOPMENTAL DELAY Global developmental delay is a term used to describe children who have marked deficits in both intellectual and physical development. Often, a specifier can be used to indicate the specific condition the child has. This can include a chromosomal abnormality, such as trisomy 21 or trisomy 18. It can also be the diagnosis in other syndromes, such as fragile X syndrome. However, specific illness is not required to make the diagnosis. On the physical side, children may have failure to thrive, which does not have significant intellectual delay; others can have an intellectual deficit, which focuses more on intellectual development. The term “developmental disability” is used to describe deficits in both physical and cognitive development. 8

The DSM-V diagnosis of 315.8 refers to global developmental delay (GDD), which was previously recognized in previous DSM manuals as “Mental Retardation, Severity Unspecified.” GDD represents developmental deficits seen in children less than 5 years of age. There are delays in cognition, speech and language, social adaptation, and activities of daily living. It is a temporary measure for kids who are too young to have a formal IQ evaluation. Many later have a diagnosis of intellectual disability later in life. It is seen in about fifteen percent of children under five. GDD is seen in a wide variety of children with different prognoses. The goal after making the diagnosis is to identify a precise etiology as this not only determines the prognosis but directs treatment. The differential diagnosis is diverse, representing genetic abnormalities, birth hypoxia, or early CNS infections (among others). An early diagnosis is critical to ensure early intervention, especially in those with severe deficits. The diagnosis of GDD is made when the actual severity cannot be determined yet in kids under 5 years of age. It is made when children fail to meet developmental milestones but cannot yet take standardized assessments reserved for older children. The developmental milestones must be in more than one area of functioning. Tests that can be done include chromosome analysis to identify genetic defects. Fragile X syndrome is a common diagnosis in GDD. In girls, one of the more common diagnoses is Rett syndrome, which has been reclassified as an autism spectrum disorder. Lead toxicity is ruled in or out in children with GDD as is congenital hypothyroidism. A CT scan or MRI of the brain can detect abnormalities causing GDD.

COMMUNICATION DISORDERS Communication disorders represent a variety of different disorders related to language and communication. This can involve deficits in producing language as in “language disorder” or things like stuttering. Speech sound disorder is the new name for Phonologic Disorder in previous DSM volumes. Social communication disorder is included in this category as well.

LANGUAGE DISORDER According to the DSM-V, language disorder can be diagnosed if there are problems with the attainment of normal language skills or the comprehension of language. This can involve the spoken word, written communication, or things like sign language. It is given the numerical label of 315.39. Unfortunately, it can be difficult to assess a child’s language skills as they can be good at using context to achieve the meaning of the spoken word. Even so, there are diagnostic criteria that need to be met in order to qualify as having a language disorder. These include the following: A. Having a consistent problem using language in its different forms (such as speaking, writing, or sign language) due to a markedly reduced vocabulary, an inability to put words together to form grammatically-correct sentences, and/or impairments in the ability to maintain conversational speech with others (which is referred to as discourse). B. The language capacity is markedly below what is expected at his or her age, which hinders social participation, communication with others, and academic performance. C. The symptoms develop during early development. D. The difficulties are not secondary to a sensory impairment, motor impairment, or another medical condition, and cannot be attributed to an intellectual disorder or global developmental delay. It is necessary to assess both expressive and receptive language skills. Expressive delays involve deficits in the production of speech or verbal signals (like sign language). Receptive delays involve the inability to receive and comprehend speech. Both skill deficits can contribute to the severity of the disorder. These deficits can be difficult to measure prior to the age of four but become easier to measure by that age. It is likely to continue through adulthood although there can be improvements over time. This problem often runs in families.

There are a number of things in the differential diagnosis of language disorder. It certainly can be a normal developmental variation that resolves as the child ages. Sensory impairment can affect the ability to produce or comprehend language. Individuals with intellectual disability will have language deficits that are a part of their overall intellectual dysfunction. Neurological disorders, like epilepsy, can interfere with language development. Language can certainly regress in a younger child, which may represent a neurological disorder or autism spectrum disorder, which doesn’t always manifest itself until after the age of three-four years of age.

SPEECH SOUND DISORDER (PREVIOUSLY PHONOLOGICAL DISORDER OR 315.39) The clarity of a child’s speech is crucial to the ability to interact socially, express intentions, and have normal occupational and educational success. It also affects self-image and selfconfidence. This disorder was called phonological disorder in the DSM-IV and includes children who have difficulties producing intelligible speech that interferes with communication, resulting in functional impairment and personal distress. The disorder represents the inability to clearly speak phonemes (the basic units of speech). These can be omitted, distorted, added, or changed in ways that make the speaker difficult to understand. The child may drop the beginning sound or ending sound of a phoneme, or may have a lisp (which is also included as part of this disorder). The complete intelligibility of a child’s speech is achieved over the course of a decade after birth with nearly all intelligibility coming by the age of 4 years. Only half of all speech is intelligible by the age of 2 years. Deficits that fall outside of these parameters in the absence of another sensorimotor problem may indicate speech sound disorder. There are four criteria for this disorder, according to the DSM-V. These include the following: A. Persistence of unintelligible speech that consists of phoneme omission, addition, substitution, or distortion that adversely affects verbal communication. B. Difficulties with academic performance, social participation, and/or occupational performance because of the speech defect.

C. Onset of the problem in childhood. D. The symptoms cannot be accounted for by another condition, including traumatic brain injury. This disorder affects 8-9 percent of children and responds well to physical therapy. The major risk factor is frequent ear infections impacting hearing. Some children also meet the criteria for language disorder. If not corrected, it can lead to social anxiety disorder. Children may be subject to bullying and later may have difficulty obtaining jobs where speech is important. The main things in the differential disorder include hearing deficits, facial abnormalities, cerebral palsy or other neurological disorder, and traumatic brain injury leading to damage to Broca’s area.

CHILDHOOD-ONSET FLUENCY DISORDER (STUTTERING) (315.35) This is also known as stuttering or stammering. It can be seen as having recurrent reverberations, blockage of sound production, or recurring prolongations of words, phrases, or syllables. The underlying problem is actually that of repetition, which is manifest as prolongations and blockages of speech in order to mask the repetition difficulty. There can be word substitution favoring words that are easier to say and tension while speaking, which worsens the problem. The child will avoid saying certain words and will avoid circumstances contributing to stuttering. About 80-90 percent of stuttering starts by age six years and 75 percent of children will recover from this. It is generally seen prior to 16 years of age, affecting about 5 percent of children. Some will continue some stuttering past adolescence. The diagnostic criteria have changed since the previous DSM IV criteria with the term “stuttering” removed and the use of speech interjections, like “um” and “you know” are no longer part of the requirements. The main addition to the criteria is the presence of avoidance and anxiety as part of the diagnostic process.

The criteria include interruptions in normal speech fluency and the time patterning of speech, as seen by at least one of these speech issues: A. Sound prolongation B. Sound and syllable repetition C. Breaks within a word D. Interjections E. Silent or audible gaps in speech F. Word substitution to avoid difficult words G. Physical tension associated with word formation H. Monosyllabic whole-word repetitions The speech disruption must impact social communication, academic achievement, or occupational accomplishments. There are speech difficulties that are unconnected or in excess of those seen with intellectual dysfunction, academic learning deficits, and deficits in adaptive functioning. People with childhood-onset fluency disorder will have difficulty finishing a word and will often require extra effort to complete certain utterances. This disorder can greatly impact a child both socially and emotionally. There may be secondary social anxiety, bullying, and difficulty with leadership responsibilities. Depression is also common with this disorder—something they struggle with into adulthood. Decreasing stress, cognitive behavioral therapy, and the use of certain electronic devices can help children with this disorder.

SOCIAL (PRAGMATIC) COMMUNICATION DISORDER Social (pragmatic) communication disorder or SCD is new to the DSM-V. It has been added in order to have a diagnostic category for individuals who have problems with verbal and nonverbal communication primarily in social settings. This can interfere with academic success, work performance, and interpersonal relationships. It is a common diagnosis among individuals with autism and other psychiatric conditions. People with this disorder who do not have a

recognizable psychiatric diagnosis have received various other diagnoses and have received inconsistent treatment in the past. The inability of SCD patients to communicate verbally or to understand properly nonverbal cues can be disastrous for patients who otherwise function at a normal level. They are not suffering from pervasive developmental disorder as was previously thought and the new diagnosis of SCD can adequately diagnose and treat these individuals. So, what is meant by the term “pragmatic”? In the language of speech professionals, it describes a person who will be able to interact appropriately in interpersonal interactions. They must pay some attention to the other speaker and take turns speaking. They must match the volume and language to the situation and to the other person. People with this kind of language impairment will have difficulty with social use of language (semantic) or will have difficulty communicating in social contacts (pragmatic). This is why it was formally known as semantic pragmatic disorder. Semantic pragmatic disorder was first proposed in 1983. It described children with very mild autism features. They were pathologically talkative but had difficulty with discourse and low vocabulary. They used certain words in an atypical way and had inappropriate conversation skills. They had other features of autism, such as striking abilities in music or mathematics. In 2002, it was suggested that language was less of a problem with these children than was processing and response. They do not understand the central meaning of terms so they become repetitive, particularly in overstimulating circumstances. According to the DSM-V, the child must have ongoing problems with verbal and nonverbal communication in social settings. Social communication is particularly impaired and the rules of conversation are not typically followed. Things like jokes and metaphors are not understood well by these individuals. All of these things together will affect participation in social activities, relationships, and the ability to function in work and academic situations. In order to qualify as having the disorder, the patient must not have cognitive impairment, intellectual delays or other developmental delays, or autism spectrum disorder.

Some children with this disorder have heightened sensitivity to sound, while others will ignore loud noises. They have increased senses of smell and taste that can lead them to dislike of many foods. Other children will have decreased awareness of hunger and won’t eat unless prompted. Certain surfaces are unpleasant to these children and the sensation of pain is often decreased unless they see blood, and then the pain awareness ramps up beyond normal. The disease may or may not be genetic but many of these children will have a parent or sibling who is affected. No one knows the incidence or prevalence of SCD as it is a new diagnosis. Many children who have previously been diagnosed with other disorders, such as autism spectrum disorder or other language disorder, will be recategorized as having this disorder. Because Asperger syndrome has been removed from the DSM-V, more children will be placed in the SCD category.

AUTISM SPECTRUM DISORDER (299.0) Autism spectrum disorder or ASD is now a single diagnosis, according to the DSM-V. This is a broadly-defined developmental disorder in which the child exhibits impairment in verbal communication, interaction with those around him, and difficulties with behavior. There is a wide range of different symptoms and deficits with this disorder and varying levels of impairment. The incidence appears to be increasing; however, there is an increased awareness that is probably a contributing factor. The incidence is believed to be about 1 in 68 children with 4-5 times as many boys having the diagnosis when compared to girls. The two main areas where symptoms are noticeable are in communication (in social situations) and behavior (with repetitive behaviors commonly seen). Impairments in both of these areas are necessary to make the diagnosis of ASD. They often have difficulty with discourse and fail to share their interests with others, failing to start or continue interactions with other people. Eye contact is often limited and there are peculiarities in nonverbal communication and the understanding of others’ facial expressions and other nonverbal communication. They cannot engage well in imaginative play and often lack interest in their peers. 15

The behavioral abnormalities often present as stereotypical motor movements and echoing the speech of others, unable to understand word meaning. They are most comfortable with rigid routines and will display aggression and frustration if the routines are changed. They are often preoccupied with objects and will underreact or overreact to various sensory inputs. According to the DSM-V. there are three levels of severity. In Level 1, the patient is said to “require support.” The biggest limitation is with language and communication deficits, with at least one life area affected by behavior. Level 2 involves “substantial support.” There are impairments in language that are present despite support. Behavioral difficulties are also prevalent in many areas of the individual’s life. Level 3 patients require “very substantial support” with limitations in all areas of the person’s life (both behavioral and communicationrelated). The onset of the disorder may not be gradual; however, the awareness that the child is not developing at the same rate as his or her peers begins by the age of three years. It is critical that the diagnosis and support begin as early in the child’s life as possible. Signs that a child might have the disorder include having a focus on objects, having little eye contact, and not engaging in play with parents or peers. These things can be seen in infancy and definitely by three years of age. Some children will acquire language skills but will lose them by the age of three years. There is a checklist called CHAT, which stands for Checklist for Autism in Toddlers, which is a screening tool for preschoolers done by pediatricians. There is cultural bias in the tool so it isn’t appropriate to children from other cultures. Things that must be ruled out when making the diagnosis in kids include hearing loss, developmental language disorder, Rett syndrome, intellectual delay, schizophrenia, reactive attachment disorder, selective mutism, and complex motor tics. Besides intensive therapy and family intervention, these children need basic healthcare. They seem to be more prone to infections and are susceptible to seizure disorders. They have behaviors and vulnerability to eating difficulties that affect their appetite and nutritional status.

Attention disorders, anxiety, and depression tend to be diagnosed more frequently in these patients.

ATTENTION DEFICIT HYPERACTIVITY DISORDER (314.0X) A child can be diagnosed with ADHD when they have elements of either inattention and/or hyperactivity/impulsivity. The symptoms need to last at least six months before the diagnosis can be made. The symptoms must also be inconsistent with the individual’s developmental level and should negatively affect social relationships, academic achievement, or occupational proficiency. They cannot be a phenomenon of oppositional behavior, hostility, defiance, or an inability to understand instructions. Older adolescents and adults must have at least five symptoms to make the diagnosis. With inattention, six or more symptoms must be present, including the following: I. Fails to pay attention to details and makes careless mistakes at work or school. J. Has difficulty sustaining attention in both work and play (especially reading, lectures, and conversations). K. Does not seem to listen when spoken to directly (seems distracted without any obvious distractions). L. Doesn’t follow through on instructions or fails to finish duties or schoolwork. M. Difficulty managing sequential tasks and cannot keep belongings in order or is disorganized. N. Avoids or dislikes tasks that involve a sustained mental effort. O. Often loses things necessary for tasks and activities (and is prone to losing about anything). P. Is easily distracted by external stimuli or internal unrelated thoughts. Q. Is highly forgetful when it comes to daily activities (like appointments, chores, returning calls, and bill-paying).

When it comes to hyperactivity and impulsivity, a child needs to have at least six symptoms, while an adult must have at least five symptoms to qualify for the disorder. Again, they cannot be secondary to opposition or inability to understand instructions. These include the following: A. Frequently fidgets or squirms in their seat. B. Frequently leaves their seat when seating is expected of them. C. Runs or climbs when this is inappropriate (or is restless as an older adolescent and adult). D. Unable to play or engage in quiet leisure activities. E. Is unable to be or uncomfortable being still for an extended period of time (on the go all the time). F. Talks excessively when this is inappropriate. G. Blurts out answers before they have been completed or cannot wait turns in conversations. H. Has difficulty waiting for his or her turn. I. Interrupts or intrudes on others. In addition, several of the symptoms must be present prior to 12 years of age and the symptoms should be present in two or more settings. There should be clear evidence that these symptoms interfere with or reduce the quality of social, occupational, or academic functioning. They should not be a part of another disorder, such as a mood disorder, dissociative disorder, or anxiety disorder. They should not be part of substance abuse or a personality disorder. There are several subclassifications under 314.0X. These include 314.02 (with a combined presentation and elements of both criteria are present), 314.00 (with primarily inattention and not hyperactivity present), and 314.01 (with primarily hyperactivity present). One should also state if the person is in partial remission and if the symptoms or mild, moderate, or severe.

SPECIFIC LEARNING DISORDERS (315) Specific learning disorder or SLD is a neurodevelopmental disorder that is biologically based. It affects a child’s (or adult’s) ability to take in or process information. Communicating information can be difficult as well. They result in various problems, including reading accuracy, comprehension, and fluency, spelling and/or written expression, and arithmetic calculation and/or math reasoning. Because of these learning deficits, there are problems in learning more complex subjects and cause a lag in academic achievement. In order to qualify for this disorder, it cannot be due to a sensory problem, such as vision or hearing deficits. The different types of learning disorders include dyslexia (or difficulty in reading) and dyscalculia (or difficulty in mathematics). There is also dysgraphia (or difficulty in writing) and Auditory Processing Disorder (or difficulty in understanding spoken instructions). The disorders are classified according to their severity. There are mild, moderate, and severe levels of severity. Learning disorders, now all clumped together as “specific learning disorder” affect 515 percent of school-age children and 4 percent of all adults. About a third of all patients will exhibit evidence of ADHD; others will have other developmental disorders, depressive disorders, or anxiety disorders. SLD can be diagnosed through careful psychometric testing. They generally have normal intelligence but have standardized testing of learning ability that falls below that expected by their age and impacts their work, school, or daily living activities. Some learning disorders are not noticeable until the child reaches school age and begin to lag behind their peers. The treatment of SLD involves specialized instruction by a special education teacher that is directed toward their specific learning problem. There are differences in specific learning disorder between old DSM volumes and DSM-V. Now, SLD is an overarching category with specifiers that indicate reading, writing, or mathematic difficulties. There is no IQ-achievement discrepancy requirement and instead there are four criteria that need to be met. Criterion A requires at least one of six symptoms present for six months or more (such as reading accuracy/fluency; spelling accuracy; written expression 19

competence and fluency; mastering number facts). Criterion B involves having characteristics and abilities that are less than expected for their age. Criterion C involves onset during childhood. Criterion D specifies the disorders that must be ruled out to make the diagnosis. These include intellectual disabilities, auditory or visual problems, neurological disorders, or inadequate instruction. The changes will help clinicians who struggled to define a specific disorder when the child has more than one area of learning affected. There are now specifiers that can be used to identify the particular learning difficulty the child or adult has. Additional learning disabilities can show up later in life that will not change the diagnosis of SLD but will just add a specifier. The shift away from having an IQ-achievement discrepancy will also not be a part of the diagnosis so children do not have to have an IQ test as part of the evaluation. Also, children with low IQ scores and an identifiable learning disability (IQ scores above 70) will be able to have the SLD diagnosis.

MOTOR DISORDERS Motor disorders comprise a wide variety of developmental disorders that include different movement disorders, usually evident in children. These can include stereotypical movements, coordination deficits, tics (vocal and non-vocal), and Tourette’s syndrome.

DEVELOPMENTAL COORDINATION DISORDER (314.5) This is a neurodevelopmental disorder that was first described as “congenital maladroitness” in 1900 and is a common developmental disorder. It was later proposed as possibly being related to “minimal brain dysfunction” as the child was otherwise neurologically normal. In 1972, it was suggested that motor incoordination stemmed from a sensory integration problem such that the child was considered clumsy for his or her age. These children have multiple deficits in fine and gross motor control. They have poor balance and timing such that they trip easily. They cannot combine movements that are sequential or

even remember sequential movements—possibly linked to proprioception deficits or lack of spatial awareness. They have left-right confusion so they cannot easily transfer objects from one hand to another. Deficits in fine motor control will interfere with activities of daily living and handwriting. They have childhood “apraxia of speech” with difficulty sequencing words and forming speech sounds. Genetic mutations in the FOXP1 and FOXP2 mutation have been seen in families where multiple members of the family have the disorder. Comorbid disorders frequently seen with this include ADHS, autism spectrum disorder, dyscalculia, dyslexia, dysgraphia, and abnormalities of muscle tone. They tend to get injured frequently, which can impair social or occupational activities. Visual-spatial memory impairment is commonly seen in these individuals. The DSM-V criteria involve a lack of ability to acquire and execute coordinated motor skills compared to children of the same age who have had ample opportunities for learning. Clumsiness and slow inaccurate performance of large and small motor skills is seen, such as catching a ball, handwriting, bicycle riding, and using utensils. These must interfere with the individual’s recreational, social, occupational, or academic activities. These will begin early in development and cannot be due to an intellectual disability or other neurological condition. Criterion A involves impaired coordination for age and is assessed differently depending on the child’s age. Very young children are assessed by not achieving developmental milestones, while older children are diagnosed with athletic disabilities and typing or writing problems. Criterion B involves the fact that these motor abnormalities interfere with activities of daily living in the major life areas. About 5 percent of children have this disorder with a higher incidence in boys. In utero exposure to drugs and alcohol and prematurity are risk factors. There are some unknown hereditary factors that play a role in getting the disorder. Neurologic testing show abnormalities in the parietal lobes, hippocampus, corpus callosum, basal ganglia, and cerebellum. There are few treatment options for this disorder but those that exist will help improve the symptoms. There is no drug therapy that helps. Cognitive motor therapy is used to teach

movement patterns to children who have problems with certain tasks. They are taught ways to improve coordination, to plan motor acts in advance, and to execute them better. Sensory integration therapy also seems to help some children as is kinesthetic therapy. Computer technology has been tried to improve coordination in certain children.

STEREOTYPIC MOVEMENT DISORDER (307.3) Stereotypic movement disorder or SMD is a neurodevelopmental condition involving several different repetitive and uncontrolled movements lasting at least four weeks. This can be seen in both children and adults but is most commonly seen in male children with intellectual delay, developmental disabilities, and neurological disorders of the nerves or brain. Head injuries can be risk factors as can stimulant abuse. Stress and anxiety will worsen the condition. The DSM-V recommends that the behavior be further indicated as to whether or not the behavior is selfinjuries, what its severity is, and whether it is from a known medical or genetic condition. Features of the disorder include nail biting, ticks, self-hitting, skin picking, hand waving, rocking, head banging, or putting one’s mouth on an object repetitively. These will interfere with activities of daily living and can be harmful to the person. Family members will recognize these behaviors as abnormal but there are no tests to identify the problem. There are several mimicking conditions to this disorder, such as OCD, chorea, autism spectrum disorder, and tic disorders. It is up to the physician to uncover the true nature of the stereotypic movement. The treatment is largely based on underlying factors. The goal is to make sure the patient is in a safe environment so they do not get injured. Some children will require helmets for head banging; others will respond to behavioral modification therapy. Desensitization and aversion therapy can help some children with stereotypic movement disorder. Drug treatment that has been prescribed for this include certain SSRIs, Anafranil, and naltrexone. While it cannot be prevented, early intervention will make a difference in stopping the behaviors as soon as possible.

PROVISIONAL TIC DISORDER (307.21) This is one tic disorder, previously known as transient tic disorder. It involves one or more vocal or motor tics that happen in childhood. The incidence is about 3-8 cases per every 1000 children. Simple motor tics are very short (like blinking, extremity extension, and shrugging). Simple vocal tics include sniffing, grunting, and throat clearing. Complex motor tics include a combination of simple tics and last for several seconds. They can involve obscene gestures or other simultaneous simple tics that last longer than just a simple tic. Mimicking others’ movements is a type of complex tic. Vocal tics that are complex include uttering swear words or other word repetitions. To make the diagnosis of this type of tic disorder, the tics have to be present for less than one year. It cannot be secondary to Tourette’s syndrome and cannot be due to the effects of a drug or to another neurological condition, such as Huntington’s disease. The tics often occur many times in a single day. The diagnosis is made when there is at least one motor or vocal tick that has been present for at least four weeks but no longer than a year. The tics must occur several times per day and cannot be due to another condition. The patient does not qualify as having Tourette syndrome or chronic tic disorder. There is a specifier as to whether this is a single or recurrent episode. DSM-V 307.20 defines tics lasting less than 4 weeks or that have an onset past 18 years. This is referred to as tic disorder NOS.

TOURETTE’S DISORDER (307.23) Tourette syndrome (TS) is also called Gilles de la Tourette syndrome. It is a chronic, inherited neuropsychiatric disorder in which there are vocal and physical tics beginning in childhood. While often linked to coprolalia (the saying of obscenities), this is not a common manifestation of the disorder. It has been described since 1885. The classification of Tourette syndrome and its differences from other tic disorders has changed over the years.

The disease is characterized by repetitive vocal and nonrhythmic motor tics involving discrete muscle groups. The most common motor tic is eye blinking, while throat clearing is the most common vocal tic. Sniffing and facial movements are also common. Echolalia (repeating others’ words) or palilalia (repeating one’s own words) happen 10 percent of the time. Coprolalia happens in 10 percent of patients as well. These tics can be voluntarily suppressed but this is exhausting and cannot be maintained. Accumulated tics can be released explosively with the feeling of an urge to do them. This makes them “semi-voluntary.” Tics start at 5-7 years of age or older with the greatest severity at age 8-12 years. Tics usually begin in the head, face, or neck. About 40 percent of patients have pure TS, while 60 percent will have tics associated with OCD or ADD. There are three tic disorders recognized: provisional (transient) tic disorder, Tourette syndrome, and chronic motor or vocal tic disorder. Chronic tic disorder involves only motor or only vocal tics (but not both). TS involves both vocal and motor tics. None of the tic disorders can be due to drugs, encephalitis, or Huntington’s disease. TS patients will have ticks many times a day for a minimum of 1 year. According to the DSM-V, the tics must start before 18 years of age but do not need to cause a significant functional impairment. According the latest epidemiological data, about 1 percent of people have a combination of motor and vocal tics seen in TS and the disease occurs four times as often in males when compared to females. The disorder is felt to be autosomal dominant with incomplete penetrance. TS and chronic motor tic disorder are similarly inherited with a high twin-twin concordance rate. It is probably monogenetic. Most cases of TS do not require treatment other than learning relaxation techniques. The comorbid conditions that need to be treated more aggressively include ADHD and OCD. Habit reversal training can be helpful and cognitive behavioral therapy can help depressive and isolation symptoms. Both haloperidol and pimozide are helpful but have a great many side effects. Many have switched to atypical antipsychotic drugs as they are better tolerated. Several other drugs, like alpha blockers and pergolide (a dopamine agonist drug), have been found to be effective. Baclofen (a GABA analogue drug) is also helpful. Nicotine patches, 24

marijuana, and deep brain stimulation have been successfully tried in some cases.

PERSISTENT (CHRONIC) MOTOR OR VOCAL TIC DISORDER A person gradually transitions from provisional tic disorder to chronic motor or vocal tic disorder if they have symptoms lasting many times a day nearly every day for a period of greater than 1 year. In addition, there cannot be a tic-free period longer than three months. The patient will have at least one motor tic or at least one vocal tic but cannot have both motor and vocal tics. The onset of the disease is prior to 18 years and cannot be due to encephalitis, stimulants, or Huntington’s disease. The patient also can never have carried the diagnosis of Tourette syndrome if diagnosed with chronic motor or vocal tic disorder.

KEY TAKEAWAYS •

Neurodevelopmental disorders can affect intellect, communication (receptive or expressive), and movement disorders.

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Intellectual disability can be present without a physical disability.

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Language disorders affect the production or understanding of speech and include things like stuttering and phonological disorder.

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There are several diagnoses under the umbrella of “tic disorders” that vary according to the type of tic and length of time of the disorder.

QUIZ 1.

What is not one of the three major criteria for diagnosing an intellectual disability? a. Onset before age 18 years b. Low level of intellect c. Deficits in adaptive behavior d. Physical abnormalities or deficits Answer: d. While many children with an intellectual disability will have a physical disability as well, this is not a requirement for having the disorder.

Which child would meet the DSM-V criteria for global developmental delay? a. A 2-year-old who does not speak and just learned to walk a few weeks ago. b. A 6-year-old who is not keeping up with other school children. c. A 10-year-old with an inability to read and who cannot do simple math problems. d. A 7-year old with a diagnosed IQ of 55. Answer: a. The diagnosis of GDD is made in children under the age of five who cannot do formal IQ testing but have delays in more than one area of functioning and/or development.

What is the most common genetic diagnosis in global developmental delay? a. Down syndrome b. Edward syndrome c. Fragile X syndrome d. Klinefelter syndrome

Answer: c. Fragile X syndrome is the most common genetic abnormality seen in global developmental delay. 4.

What percent of childhood-onset fluency disorder ultimately resolve their stuttering by the time they reach adulthood? a. 5 percent b. 50 percent c. 75 percent d. 95 percent Answer: c. About 75 percent of children with stuttering will resolve their disorder by the time they reach adulthood.

Which language disorder most closely resembles children who have autism spectrum disorder? a. Language disorder b. Social (pragmatic) communication disorder c. Speech sound disorder d. Childhood-onset fluency disorder Answer: b. Children with SCD have peculiarities in their understanding language and in discourse that make them share features in common with autism spectrum disorder.

Patients with milder autism spectrum disorder tend to have more problems in what area of functioning? a. Repetitive behaviors b. Language acquisition c. Attachment to rituals d. Communication deficits

Answer: d. When the patient has milder disease, they tend to have more problems with communication deficits than they do with behaviors. They tend to acquire language (albeit peculiarities of language) at a normal age. 7.

What is not an exclusion to the diagnosis of specific learning disorder? a. Hearing or vision deficit b. Neurological disorders c. Inadequate instruction d. Borderline IQ score Answer: d. No longer are IQ scores required for the diagnosis of SLD so patients who have borderline IQ scores can be included under the umbrella of this disorder.

Children who have clumsiness and poor motor skill acquisition are said to have what disorder? a. Pervasive developmental disorder b. Stereotypic movement disorder c. Developmental coordination disorder d. Unspecified movement disorder Answer: c. Children with developmental coordination disorder have poor acquisition of motor skills and clumsiness in large and small motor areas.

How long does a child have to have stereotypic movements in order to have a diagnosis of stereotypic movement disorder? a. 4 weeks b. Three months c. Six months d. One year

Answer: a. The symptoms must be present for a minimum of four weeks to make the diagnosis of stereotypic movement disorder. 10.

Which drug has not been found to be helpful in the treatment of Tourette syndrome? a. Baclofen b. SSRIs c. Atypical antipsychotics d. Alpha blockers Answer: b. While SSRIs can treat OCD, which can be comorbid with TS, they are not directly related to the treatment of TS itself.

CHAPTER TWO: SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS This chapter focuses on psychotic disorders and disorders that resemble schizophrenia. They range from the very short duration of brief psychotic disorder to the lifelong personality disorder called schizotypal personality disorder. Each of these will have characteristic psychotic features as a main component of the disorder but will differ in overall symptomatology and length of the illness.

SCHIZOTYPAL PERSONALITY DISORDER (301) Schizotypal personality disorder or SPD is one of six different personality disorders recognized by the DSM-V. People with this disorder are considered to have odd thinking or behavior that result in significant social deficits. These people prefer to live alone and have a lack of interest in social situations. They frequently live in a fantasy world. They are apathetic, emotionless, and cannot express their emotions. Depression and frank psychosis can be present. They have difficulty showing intimacy in relationships and developing relationships in the first place. The disorder shares some features with schizophrenia but it is a separate disorder. Patients with SPD are innately introverted but may mask this with an engaging and interesting overlay they project without emotion to others. They tend toward being secretive and have many more acquaintances than they do true friendships. Interpersonal problems are common. Positive symptoms include paranoia and delusions, while negative symptoms include a lack of expression of emotion, apathy, and social skill deficits. Those with a lot of positive symptoms will have a high rate of suicide. Coexisting disorders include anxiety disorders, depression, borderline personality disorder, and narcissistic personality disorder.

There may be mild to severe psychosocial impairments in daily living with schizotypal personality disorder that may affect occupational functioning; however, this is less commonly seen when compared to paranoid personality disorder and schizophrenia. It does impact social functioning at work, which can affect overall performance. They tend not to be able to engage in small talk with colleagues and do better in a job that doesn’t have a great deal of interpersonal contact. People with SPD do form relationships and can have spouses but will have a stronger connection to a person of the same background or profession and less to a true emotional connection. They prefer to be in control in a relationship and are governed by rules rather than feelings. They often indicate that they have a great many stressful life events. Their strongly negative affect will impact their quality of life. These patients respond well to psychotherapy, although antipsychotics are sometimes unnecessarily recommended. They attend therapy to address fantasies and delusional thinking. They attempt to connect the delusions to the everyday stresses in their lives. Creative therapeutic approaches tend to be helpful in these situations. Behavioral training can help develop social interaction skills and can improve their interpersonal maladjustment. Group therapy helps them develop better social skills.

DELUSIONAL DISORDER (297.1) As psychotic disorders go, delusional disorder is far less often diagnosed. Patients have a predominance of delusions but do not have a thought disorder, mood disturbance, flat affect, or hallucinations. There have been some slight changes to the diagnosis in the DSM-V in order to improve the reliability of the diagnosis. With delusions, the patient will have a strongly-held belief despite the actual evidence against its truth. It is not a misunderstanding, illusion (abnormal perception), or confabulation. The initially-held criteria for a delusion (developed in 1913) still hold true today. There is certainty (in which the belief is held with conviction), incorrigibility (the belief cannot be

changed with contrary proof), and falsity (the belief is not true). While delusions can be a part of many different psychiatric and neurologic disorders, they are particularly seen in psychoses like delusional disorder. There are four different types of delusions: mood-congruent, mood-neutral, bizarre, and nonbizarre. Bizarre delusions are, by definition, odd and completely implausible (like being invaded by aliens). Non-bizarre delusions are unlikely but still within the realm of plausibility. Moodcongruent delusions are in keeping with the patient’s mood (such as being manic and believing one is all-powerful or influential). Mood neutral delusions are unrelated to the individual’s actual mood and are simply false beliefs. There are recurrent themes in many delusions. They include things like being controlled, having one’s mind read, having thought insertion, delusions of grandeur, delusions of persecution, ideas of reference, self-accusation, having somatic changes (such as disease or having a terminal illness), having sexual involvement with someone (when there is none), and jealousy. Somatic delusions are more closely linked to mood disorders than other delusions and may actually represent another disorder (like body dysmorphia). Delusions of persecution or grandiosity are related more often to schizophrenia and other psychoses. Delusional disorder is considered a primary disorder that has no specific medical or neurologic cause. It tends to be chronic and may last a lifetime. The patient’s general logical reasoning is normal with the exception of the delusional thoughts and related reasoning. Any abnormal behavior is usually related specifically to the delusion. Trivial or unrelated events tend to carry great importance through their connection to the delusional belief. No one knows the exact cause of delusional disorder; however, it does appear to be somewhat controllable with small doses of haloperidol. There appears to be some genetic variation to patients with delusional disorder, indicating a hereditary component. People who are under chronic stress and who have impairments in vision or hearing have a higher incidence of delusional disorder. Certain right cerebral and bilateral frontal lobe lesions will lead to delusional thinking. Many patients function fairly well despite their delusions and

resist getting psychiatric help. The prevalence is about 30 cases out of 100,000 people. It accounts for only 1 percent of psychiatric hospitalizations. The DSM-V diagnosis of delusional disorder requires symptoms lasting at least a month and the patient must not have met Criterion A for schizophrenia (as in no hallucinations, catatonia, disorganized behavior, abnormal speech, or negative schizophrenic symptoms). There should be no wide-reaching problems with functionality except that related directly to behaviors regarding the delusion. Mood disturbances, if present, must be shorter in duration than the delusions. The delusion cannot be due to another medical or psychiatric condition or to the effects of a substance. Delusions can be classified by type—according the predominant theme. There are erotomanic delusions that someone in power is in love with them, grandiose delusions of power, wealth, and importance, jealous delusions that one’s partner is cheating on them, persecutory delusions, and somatic delusions of having an illness or deformity. The major change with the DSM-V was that the delusions now can be bizarre rather than only non-bizarre, as long as they cannot be explained by having another disorder. In addition, there is no such thing as a shared delusion anymore. If two people have the same delusion, they both have delusional disorder. Individuals with delusional disorder are difficult to treat because delusions are so central to their lives and they tend not to want to be treated. In addition, they are not very compliant with medications or other treatment. It takes a non-confrontational approach with the involvement of family if possible to help the patient maintain normal social functioning despite having delusions. Drugs that have been found to be helpful include pimozide and typical antipsychotic drugs. More recent studies on atypical antipsychotics have found 90 percent improvement rates. Persecutory delusions have been found to have the worst prognosis. SSRIs seem to help patients with somatic delusions.

BRIEF PSYCHOTIC DISORDER (298.8) Brief psychotic disorder is a transient thought disorder seen primarily in late adolescence or early adulthood. While it does not last long, it can result in an inability to care for oneself and increases the suicide risk. There will be at least one of the following findings: A. Hallucinations, which may be visual or auditory in nature B. Delusions C. Disorganization of speech (incoherence or having irrational content) D. Disorganized behavior—this may involve catatonia or repetitive and senseless movements In order to have a brief psychotic disorder, the symptoms must last at least one day but must resolve after a month. It cannot be due to the use or withdrawal from a substance or from a medical disorder causing delirium. It cannot fit the diagnostic criteria for schizophrenia, bipolar disorder with psychotic features, or major depressive disorder with psychotic features. The DSM-V uses five specifiers to further describe brief psychotic disorder. These include the following: A. With marked stressors—having a significant stressor precede the psychotic episode B. Without marked stressors—having no preceding significant stressor C. Postpartum—occurring in late pregnancy or within a month of delivery D. With catatonia E. Severity—given as a scale from zero being absent to four being very severe In general, the episode lasts less than two weeks and resolves within a month of onset. The onset is usually secondary to a major stressor or stressors that overwhelm the coping skills of the patient. It is twice as often seen in women and is seen in adolescence or young adulthood. Acute or chronic stress with lack of social support and isolation is a typical risk factor. Trauma is considered the major risk factor with personality disorders being a minor risk factor. Borderline personality disorder and paranoid personality disorder are risk factors as well. 35

The differential diagnosis of things that should be ruled out before making a diagnosis include using sympathomimetic drugs (like methamphetamine and cocaine), alcohol withdrawal, and the use of psychedelic drugs. A toxicology screen should be checked when evaluating a possible case of brief psychotic reaction. Dehydration and delirium can be in the differential diagnosis. Traumatic brain injury can produce psychotic symptoms as well. The presence of negative symptoms indicates schizophrenia more than brief psychotic disorder. Unipolar and bipolar depression can have psychotic features that are not part of brief psychotic disorder.

SCHIZOPHRENIFORM DISORDER (295.40) This is part of the schizophrenia spectrum in the DSM-V. It is very similar to schizophrenia but it develops faster and lasts for a briefer period of time. Like other disorders in this spectrum, it is disabling and severe, with both negative and positive behavioral symptoms and thought problems. There appears to be a genetic predisposition to the disorder. There is also a probable abnormality of dopamine neurotransmission with a clinical response to both medications that block dopamine and psychotherapy. There have been no changes in the diagnostic criteria for this disorder but there have been changes to the diagnosis of schizophrenia itself. The only real difference between schizophreniform disorder and schizophrenia is the length of symptoms and the degree of impairment. For schizophrenia, the symptoms last longer than six months, while for schizophreniform disorder, the symptoms last less than six months. Because of the shorter duration of symptoms, there may not be the same social, academic, and occupational impairment as is seen in schizophrenia. It is a provisional diagnosis in psychotic individuals who have not had symptoms longer than 6 months. There may be positive symptoms (thought disorder, catatonia, hallucinations, delusions, disorganized speech, and behavioral disorganization); or negative symptoms (flat affect and anhedonia, lack of interest in social relationships, and lack of motivation). About 66 percent of schizophreniform disorder patients eventually carry the diagnosis of schizophrenia. Unfavorable prognostic features include the presence of negative symptoms and lack of eye contact. 36

According to the DSM-V, there are several things necessary to make the diagnosis. There needs to be a month-long period of time where at least one of the following are true: hallucinations, delusions, or disorganized speech. There may also be disorganized behavior, such as catatonia. The symptoms can be present for less than a month if they have been treated successfully. Six months is the limit on time and there can’t be any affective symptomatology during that time. Substance abuse or withdrawal cannot be a factor. Good prognostic features include the onset of psychosis within 4 weeks of the first noticeable behavior change, good social or occupational function before symptom onset, and/or symptoms accompanied by perplexity or confusion. If these are not present, it Is considered to be “without good prognostic features.” The disorder affects both males and females with equal prevalence but it occurs at a younger age with males. It is not diagnosed as often as is schizophrenia in developed countries. The incidence is higher in developing countries and is usually seen with good prognostic factors. Schizophreniform disorder is often treated with antipsychotic drugs and sometimes by antidepressant and antimanic drugs. Atypical antipsychotics are now preferred over typical antipsychotic drugs. If these alone do not resolve the symptoms, then mood-stabilizers, SSRIs, Lithium, or SNRI drugs are used. ECT (electroconvulsive therapy) has sometimes been found to be effective.

SCHIZOPHRENIA (259.90) The DSM-V classifies schizophrenia as being a psychotic thought disorder that lasts a minimum of six months. While it appears in young adulthood, it is believed to be highly hereditary, with patients having periods of relapse and remission throughout their lives. Most relapses come from not taking the proper medicine. The newer antipsychotic drugs have fewer side effects than the older drugs but patients still stop taking them because they think they no longer need of them.

Schizophrenia is defined as having two or more symptoms listed here with one that must be delusions, hallucinations, or disorganized speech. Other possible symptoms that can be present include repetitive senseless movements, catatonia, apathy, flat affect, lack of motivation, lack of energy, and failure to maintain adequate hygiene. This must affect occupational, personal care, or social areas of the patient’s life with an inability to reach age-related functioning in many life areas. Symptoms must last at least six months. Schizoaffective disorder, bipolar disorder with psychotic features, and depression with psychotic features must be ruled out as must psychosis secondary to ethanol withdrawal, cocaine abuse, or a medical condition. There are several specifiers that can be used if the disease has been present for at least a year, including the following: A. First episode that is currently acute B. First episode that is in partial remission C. First episode that is in remission D. Multiple episodes in an acute phase E. Two or more episodes, currently in an acute phase F. Multiple episodes, currently in remission G. Multiple episodes in partial remission H. Continuous symptoms I. Unspecified with catatonia J. Current severity from the five-point Likert scale (0-4, with four being the most severe) The onset of the disease is rare before adolescence or after 35 years of age. The peak age for men is 20-25, while the peak age for women is older than 26 years. The onset can be insidious or abrupt with about half of all patients having some depressive symptoms. The incidence is about 1 percent of the population. Chemical dependency and tobacco use are common comorbid conditions as is anxiety. There are many comorbid medical conditions that make their lifespan shorter than average.

SCHIZOAFFECTIVE DISORDER (295.70) The main features of schizoaffective disorder include a combination of psychotic and moodrelated symptoms. The patients commonly have delusions, hallucinations, and depression. Interestingly, there is ongoing discussion as to whether this should be a distinct psychiatric disorder as many patients with schizophrenia have depressive symptoms. In order to carry the diagnosis of schizoaffective disorder, the patient must have at least two weeks of some type of mood-related episode with the presence also of hallucinations and delusions. The symptoms must not be secondary to medications, drugs, or medical illness. Difficulty with work is often seen but is not a requirement. There are two major types of schizoaffective disorder: depressive type and bipolar type (which includes manic episodes). The Likert scale is used to indicate severity. According to the DSM-V, mania and psychosis are the most prominent aspects of the disorder. Patients can also have night eating syndrome (binge-eating at night), insomnia, disorganized speech, disorganized thinking, and suicidality. Paranoia can be seen as are mood swings and neglect of personal hygiene. They tend to speak very fast—to the point where others are unable to interrupt. Some patients can be extremely isolative. The disease appears to share a common genetic link to schizophrenia and bipolar disorder but the biological factors seen in schizoaffective disorder are slightly different than in either disorder. Low levels of a crucial protein called arrestin is linked to schizophrenia but not to schizoaffective disorder. Studies of the brain show differences between the two diseases. The exact genes responsible for schizoaffective disorder are not yet known.

SUBSTANCE OR MEDICATION-INDUCED PSYCHOSIS (292.9) This involves having psychotic symptoms that are directly related to the use of a substance. There are ICD-10 sub-codes that vary according to both the substance used and the degree of use the patient has been involved in (as in mild, moderate, or severe). There are specific sub-

codes for the following common substances of abuse: A. Marijuana B. Phencyclidine C. Miscellaneous hallucinogens D. Inhalants E. Sedatives, anxiolytics, or hypnotics F. Stimulants (like amphetamines) G. Cocaine H. Other substance Patients at risk include those who have a prior mental health issue. They can have exaggerated symptoms when taking certain drugs. Some substances, when taken for a long time, can mimic schizophrenia or bipolar disorder. The patient must have the presence of hallucinations or delusions as part of their psychosis. Most of the hallucinations are visual in nature. Alcohol can induce this disorder but it usually happens in the presence of a prior mental illness. The substance-induced psychosis usually passes after the drug wears off but this isn’t always true if the substance use was excessive and/or prolonged. The symptom list is long and includes negative symptoms, cognitive impairment, delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and depressed symptoms. The patient must have either delusions or hallucinations or both as part of the diagnostic symptomatology. The symptoms must start after using or withdrawing from the drug. Delirium as a cause of the symptoms must be specifically ruled out. The symptoms cannot be side effects of the medication itself. In most cases, the psychosis should resolve simply by removing the substance and allowing its effects to wear off. If it doesn’t reduce the symptoms, then a primary psychosis must be the correct diagnosis. Delusions can be treated with persistent, gentle cognitive-behavioral therapy. After the psychosis has resolved, supportive therapy and drug counselling might need to take place to prevent a recurrence.

PSYCHOTIC DISORDER DUE TO A MEDICAL CONDITION Many medical disorders can result in delusions, hallucinations, disorganized speech, disorganized thinking, and/or catatonia or other motor behavior. The medical disorders that can include psychosis include temporal lobe epilepsy, parietal lobe brain tumors, dementia (of different types), migraine, stroke, CNS infections, and some endocrine disorders. The hallucinations can be of any type, including olfactory and tactile hallucinations. Things that must be ruled out include ICU psychosis, drug use or drug withdrawal, and delirium. Often, treating the medical disorder will reduce the psychosis; however, antipsychotic drugs may need to be utilized.

CATATONIA (MULTIPLE DSM-V CODES) Catatonia is not a separate DSM-V diagnosis but is a specifier to other psychotic disorders, including that related to another medical condition and that related to another mental illness. It is a symptom that is manifest as neurogenic motor immobility and stupor. There can be specific postures involved and the resistance to changing postures and the absence of speech. Common symptoms include staring spells, social and cognitive withdrawal, rigidity, echolalia, and echopraxia. It can be associated with excitement, agitation, and aggression. Common disorders linked to catatonia include bipolar disorder, autism spectrum disorder, schizophrenia, and depression. Stupor is the most common characteristic of this phenomenon. The person is unresponsive to most stimuli with the exception of pain. It can be seen in disorders unrelated to catatonia that must be ruled out, such as hypothermia, infectious diseases, neoplasms, and drug abuse. In the DSM-V, catatonia is a specifier of mood disorders, schizophrenia, schizophreniform disorder, substance-induced psychotic disorder, and brief psychotic disorder. There is a special category called Catatonia-not otherwise specified. The same symptoms are part of the diagnosis in all categories. This means that catatonic schizophrenia does not exist as a diagnosis. 41

KEY TAKEAWAYS •

Psychotic disorders are on a spectrum from brief psychotic disorder to schizophrenia to schizotypal personality disorder.

•

Most of the disorders on the schizophrenia spectrum have the same symptoms but a different length of symptomatology.

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Psychosis can be from a substance use, substance withdrawal, or to a medical condition.

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The key features of psychosis are delusions, hallucinations, and disorganized speech.

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Catatonia is not a separate diagnosis but is a specifier to several other mental illnesses.

QUIZ 1. How many different personality disorders are represented in the DSM-V? a. 4 b. 6 c. 8 d. 10 Answer: b. There are six recognized personality disorders in the DSM-V that are arranged in three clusters. Schizotypal personality disorder is one of these personality disorders. 2.

What is considered a positive symptom of schizotypal personality disorder? a. Social skills deficits b. Apathy c. Lack of emotional expression d. Delusions Answer: d. Paranoia and delusions are the two main positive symptoms seen in schizotypal personality disorder. The negative symptoms include the other symptoms listed.

What psychiatric disorder is least likely to be associated with schizotypal personality disorder? a. Dissociative amnesia b. Major depressive disorder c. Generalized anxiety disorder d. Borderline personality disorder

Answer: a. Each of these is considered a comorbid condition with schizotypal personality disorder except for dissociative amnesia, which would not typically be seen with this disorder. 4.

According to the DSM-V, if two people have the same abnormal belief/delusion, what is this called? a. They both have delusional disorder b. Mixed delusion c. Shared delusion d. Folie à deux Answer: a. There have been changes in the DSM-V so that shared delusions do not exist as a diagnosis. They are both separately diagnosed. A mixed delusion has features of different delusion types.

Which type of delusions in delusional disorder have the worst prognosis in terms of treatment? a. Somatic delusions b. Persecutory delusions c. Erotomanic delusions d. Delusions of grandeur Answer: b. Patients with persecutory delusions are difficult to treat and respond poorly to antipsychotic medications when compared to people who have other types of delusions.

How long do the symptoms of brief psychotic disorder need to be present for the diagnosis to be made? a. One day b. Two weeks c. One month d. Three months Answer: a. The diagnosis of brief psychotic disorder can be made if the symptoms are present for just one day. The symptoms cannot last longer than one month.

The patient with schizophreniform disorder can have any of these symptoms: hallucinations, delusions, disorganized speech, and disorganized behavior. How many of these symptoms must be present for a month to qualify as having the disorder? a. 1 b. 2 c. 3 d. 4 Answer: a. Just one of these symptoms needs to be present in order to make the diagnosis.

Which is not one of the mandatory symptoms necessary for the diagnosis of schizophrenia? a. Delusions b. Hallucinations c. Flat affect d. Disorganized speech

Answer: c. At least one of the mandatory symptoms must be present to make the diagnosis; however, flat affect is an optional symptom. 9.

In diagnosing schizophrenia, what is the Likert scale? a. A measure of the patient’s social functioning b. A measure of severity of the disease c. A scale that differentiates between types of hallucinations d. A scale that differentiates between states of active disease to remission Answer: b. The Likert scale is a 5-point scale that is a measure of disease severity in schizophrenia.

10.

What is the most common feature seen in catatonia? a. Stupor b. Aggression c. Echolalia d. Echopraxia Answer: a. Being stuporous is commonly associated as a major feature of catatonia, although the other symptoms can also be seen.

CHAPTER THREE: BIPOLAR AND RELATED DISORDERS This chapter covers disorders that fall under the umbrella-term of “bipolar disorders.” These are related mood disorders that are characterized by extreme fluctuations in mood. By definition, these patients will have at least one manic episode as seen by an elevation in mood. Some patients will have a reduction in mood when not truly manic. A select few will have rapid-cycling disease with frequent fluctuations in mood.

BIPOLAR I DISORDER (296) The phenomenon of extremes of mood have been understood to be an illness since the time of Hippocrates; however, it was not recognized as a mental illness until the 19th Century. By 1900, it was differentiated from schizophrenia and was called “manic-depressive psychosis.” The term manic-depressive disorder was altered in the 20th Century to be identified as bipolar disorder or bipolar spectrum disorder. The main feature of bipolar I disorder is at least one manic episode with or without hypomania or depression. This is distinguished from bipolar II disorder, which must have at least one depressive episode with hypomania present at least once. True mania is not required for bipolar II disorder. Previous editions of the DSM had a catchall category called “bipolar disorder NOS” for indeterminant manic-depressive illness. This phenomenon of having an “NOS” category has been dropped in the DSM-V in favor of an “unspecified” category, in which there is not enough information to make a specific diagnosis and not because the disorder, such as “bipolar disorder” didn’t fit into one of the known categories. The DSM-V also recognizes that anxiety can aggravate bipolar disorder, while not having anxiety as a part of the diagnostic criteria

necessary. The feature that must be seen in bipolar I disorder is mania. It must last at least a week and must be seen as an elevated or irritable mood. The patient may be grandiose, anxious, hostile, irritable, or euphoric. There will be increased energy levels, increased sex drive, decreased need for sleep, and decreased attention span. Other things commonly seen include substance abuse, inappropriate behavior, and impulsivity. The feature of the psychosis seen in severe mania is that it has all of the features of other psychoses but it does not exhibit hallucinations. The manic phase itself must last a minimum of one week; however, there can be preceding symptoms for up to three weeks before the episode. Commonly seen are changes in appetite, sleep disturbances, and alterations in activity level. The depressive episodes, if seen, do not have to last longer than two weeks (as is the case in major depression) but the depression can lead to true psychosis, complete with hallucinations and delusions. Patients exhibiting hypomania will often feel more optimistic than irritable and may feel productive. The grandiosity of mania is less prevalent and speech is slightly pressured. There is an increased energy level and decreased need for sleep with evidence of hypersexuality. Hypomania does not involve delusions or hallucinations. True manic patients tend to be more irritable and are less productive than in those having hypomania. There has been an increasing recognition of “mixed episodes” that share features of both mania and depression. The delusions tend to be related to depressed themes and the activity level and irritability are great enough so that suicidality is greatest with this type of symptomatology. Substance abuse and unpredictable behavior are also prominent in mixed episodes. These symptoms do not better fit that of schizoaffective disorder, schizophrenia, or delusional disorder. According to the DSM-V, a manic episode can involve an irritable, expansive, or elevated mood with increased energy levels and activity lasting at least a week. Three of the following symptoms must be met (or four of them, if irritability is the major presentation):

A. A sense of inflated self-esteem or irritability B. Decreased need for sleep C. Increased talkativeness D. Distractibility E. Psychomotor agitation F. Flight of ideas or racing thoughts G. Increased goal-directed behavior H. Increased risky behavior These must be severe enough to cause hospitalization, psychosis, or occupational/social impairment. They cannot be secondary to a medical condition or substance abuse. Mixed episodes need hypomania or mania plus at least three depressive symptoms at the same time. The depressive symptoms include depressed mood, self-reproach or guilt, worry, hopelessness, negative self-evaluation, fatigue, anhedonia, suicidal thoughts, or psychomotor retardation. The major DSM-V change in bipolar I disorder involves the addition of increased activity and energy without only an elevated mood. Mixed episodes can involve hypomania and depression, rather than the simultaneous existence of mania and depression. Another specifier includes “anxious distress,” which identifies patients that also have severe anxiety with their mixed features. The lifetime prevalence of bipolar I disorder is about 2 percent. It affects men and women equally and has about the same prevalence in all parts of the world. The incidence is slightly less in Asian populations. Half of those who are hospitalized for their first manic episode will recover within six weeks and nearly 98 percent will be asymptomatic after two years. Forty percent had a recurrent episode within two years after initial recovery with less than 20 percent having a depressive episode. About a third have attempted or completed suicide. There is a genetic component to all bipolar disorders with a monozygotic twin-twin concordance rate of 40 percent (with only a 10-20 percent rate in dizygotic twins). If all types of bipolar disease are included, the heritability factor is about 0.71. There have been no

specific genes yet identified but it is believed that there is more than one gene playing a role. There are nonspecific EEG changes seen as well as functional MRI changes in the limbic system. There is increased dopaminergic transmission in manic episodes and a decreased transmission in depressive episodes. Glutamate is increased in mania as is GABA. Cortisol is increased in both manic and depressive episodes. The treatment of bipolar I disorder depends on mood stabilizers, which prevent both mania and depressive episodes. Maintenance therapy is required to prevent recurrences. Antidepressants can trigger manic phases, particularly in bipolar I disorder, so these are contraindicated in bipolar I but not bipolar II disorder. Mood stabilizers include lithium and certain anticonvulsant drugs. Lithium has been in use since 1949 and has been found to prevent mania and reduce the risk of suicide. Anticonvulsant drugs include carbamazepine, valproate, topiramate, lamotrigine, and divalproex. Atypical antipsychotics have been approved also for stabilizing bipolar episodes.

BIPOLAR II DISORDER (296.89) This disorder is seen as having depressive episodes and hypomania (episodes of euphoria). It differs from mania in that these patients can function better in life than patients with true mania as is seen in bipolar I disorder. Hypomania does not involve psychosis and hospitalization is required for mania in many cases but not for hypomania. One of the new changes to the DSM-V (besides the addition of activity and energy level increases) is a change in the mood criteria. There has been the addition of hopelessness. The hypomania in bipolar II disorder must last for most of the day for a minimum of four days with the presence of at least three of these symptoms: A. Increased talkativeness B. Less need for sleep C. Grandiosity or increased self-esteem

D. Increased involvement in high-risk activities, agitation, or increased goal-directed behavior E. Distractibility F. Racing thoughts or ideas G. A lack of a manic episode or mixed episode This can often be mistakenly diagnosed as having borderline personality disorder or major depression. Under the DSM-V, there is a separate classification for depressive disorders and bipolar disorders. Many patients with bipolar II disorder need maintenance medication. There can be occupational difficulties, social difficulties, and problems with concentration. Most patients can learn to recognize the triggers for an episode and can adapt their life to prevent a recurrence. The treatment of bipolar II disorder involves a combination of drugs (antipsychotics, mood stabilizers, and antidepressants) and interventional therapies. Family therapy can help as can group interpersonal and social rhythm therapy. Cognitive behavioral therapy can also be helpful in managing episodes. According to many recent studies, psychotherapy is preferable to medications for this disorder.

CYCLOTHYMIC DISORDER (301.13) The diagnosis of cyclothymic disorder or “cyclothymia” is made in individuals who have mood cycling that lasts a minimum of two years and who do not meet the diagnostic criteria for depressive disorder, bipolar I disorder, or bipolar II disorder. There are a number of things to rule out (including the above) and there is ongoing debate as to whether this is a premorbid state for a bipolar disorder or a temperamental state or personality variation. About 15-50 percent will develop bipolar I or bipolar II disorder. It is possible to diagnose in children but is difficult as their behavior under normal circumstances already lend themselves to labile mood and lack of emotional control.

There are six diagnostic criteria (that must last for two years) with hypomanic and depressive episodes that aren’t true depression or mania. The symptoms must be present for at least half the time during a two-year period of time. No more than two months can pass without symptoms. The symptoms cannot be psychotic in nature and cannot be due to a substance or medical condition. The symptoms must cause impairment of social or occupational functioning or some distress. The only specifier is that of “with anxious distress.” With adolescents or younger, the symptoms must be present for at least a year. The prevalence over a lifetime of cyclothymia is less than 1 percent with equal prevalence in males and females. The greatest risk factor is having a first-degree relative with bipolar I disorder. Major comorbidities are substance abuse (with an attempt to self-medicate), sleep disorders, and ADHD (among children with the disorder). While the DSM-V does not specify treatments for cyclothymic disorder, common treatments include mood stabilizers and cognitive behavioral therapy. Medical conditions that can mimic cyclothymia include hypothyroidism and hyperthyroidism. These are tested for by doing thyroid hormone levels and a TSH level. It should be noted that subtle thyroid disease is seen at a high frequency with bipolar disorders in general, particularly in those who have rapid-cycling bipolar features.

MEDICATION OR SUBSTANCE-INDUCED BIPOLAR DISORDER This describes the presence of mania, hypomania, or major depressive episode that is directly caused by the taking of a medication or its withdrawal. The changes must be prominent and persistent in order to make the diagnosis. There needs to be a temporal relationship between the onset of use of the drug or substance, its withdrawal, and the symptoms of bipolar disorder. Typical symptoms necessary to make the diagnosis include manic or hypomanic symptoms and depressive symptoms.

Mania-related symptoms include: A. Elevated self-esteem B. Marked decrease in sleep C. Excess talkativeness D. Poor concentration/distractibility E. Engagement in risky behavior F. Engaging in uncharacteristic behavior Depressive symptoms that can occur include the following: A. Feeling empty, sad, or hopeless B. Anhedonia C. Weight changes over a short period D. Sleeping more or less than normal E. Lack of energy or fatigue F. Poor concentration In all cases, delirium from a substance must be ruled out and include having a normal level of arousal, a lack of hallucinations, and a lack of delusions. Drugs that typically are related to this disorder include alcohol, PCP, hallucinogens, and amphetamines.

KEY TAKEAWAYS •

Bipolar disorders as a category are distinctly separated from depressive disorders in the DSM-V.

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There is a predominance of mania in bipolar I disorder and a greater chance of depression in bipolar II disorder.

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Patients with cyclothymia must have symptoms for two years and no symptom-free period of longer than two months. The criteria specifically exclude true mania and true depression.

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Substance and medication-induced bipolar disorder involves symptoms related to the use or withdrawal from a substance. PCP, amphetamines, hallucinogens, and alcohol are commonly associated drugs that can cause this.

QUIZ 1. What is the major distinguishing feature separating bipolar I disease and bipolar II disease? a. Bipolar I disease must have multiple manic episodes, while bipolar II disease does not. b. Bipolar I disease does not have depressive episodes, while bipolar II disease has depression. c. Bipolar I disease does not have fully manic episodes, while bipolar II disease has them. d. There must be at least one depressive episode in bipolar I disease but not in bipolar II disease. Answer: b. Bipolar I disease must have at least one manic episode but does not necessarily have any depressive episodes, while bipolar II disease must have at least one depressive episode. 2.

How does the DSM-V incorporate anxiety into the diagnosis of bipolar disorder? a. It is part of the diagnostic criteria for cyclothymia but not a necessary one. b. It is a necessary criterion to be met in bipolar I and bipolar II disorders. c. It is recognized as an aggravating factor but is not one of the diagnostic criteria for bipolar disorder. d. It is recognized as a causative factor behind the development of mania but not depression. Answer: c. In the DSM-V, anxiety is recognized as an aggravating factor behind the symptomatology but is not a part of the diagnosis of bipolar disorders.

What feature is not seen in severe cases of bipolar I mania that may be present with other psychotic disorders? a. Disorganized speech b. Thought disturbance c. Delusions d. Hallucinations Answer: d. While many features of psychosis can be seen in severe mania, there are no hallucinations as part of this diagnosis.

What is not one of the main disorders that must be ruled out before the diagnosis of bipolar disorder can be considered? a. Schizoaffective disorder b. Schizophrenia c. Delusional disorder d. Schizoid personality disorder Answer: d. As schizoaffective disorder, schizophrenia, and delusional disorder can be similar to bipolar disorder, they must be examined and ruled out before the diagnosis of bipolar disorder can be made.

Which symptom has recently been added as part of the diagnosis of bipolar I disorder that didn’t exist in prior editions of the Diagnostic and Statistical Manual? a. Increased energy and activity b. Flight of ideas c. Distractibility d. Increased risky behavior

Answer: a.The finding of increased energy and activity as part of the diagnostic process is new to the DSM-V, while the other diagnostic criteria existed previously. 6.

Which classification of drugs is relatively contraindicated in bipolar I disorder? a. Mood stabilizers b. Antidepressants c. Atypical antipsychotics d. Anxiolytic drugs Answer: b.The use of antidepressants in type I bipolar disorder is risky because they can precipitate an episode of mania. They are not recommended for this disorder but can be useful in bipolar II disorder when used with mood stabilizers.

Which drug therapy is least preferred in bipolar II disorder? a. Atypical antipsychotics b. Antidepressants c. Mood stabilizers d. Benzodiazepines Answer: d. Each of these can be helpful in treating bipolar II disorder; however, benzodiazepines can be addictive and are not generally beneficial in treating the symptoms seen in the disorder.

What is not one of the main disorders that must be ruled out in patients suspected of having cyclothymia? a. Schizophrenia b. Depressive disorder c. Bipolar I disorder d. Bipolar II disorder

Answer: a. As cyclothymia can mimic several of these disorders, they must be ruled out as part of the diagnostic process. Schizophrenia is too distinct to be in the differential. 9.

According to the DSM-V, how long must cyclothymic disorder symptoms be present in order to make the diagnosis? a. Two weeks b. Six months c. Two years d. Four years Answer: c. The symptoms must be present for a minimum of two years to make the diagnosis of cyclothymic disorder. Mild to moderate extremes of mood are the major diagnostic criteria for the disorder.

10.

Which drug is least likely to be associated with medication-induced bipolar disorder? a. PCP b. Hallucinogens c. Sedative/hypnotics d. Amphetamines Answer: c. Each of these (and alcohol) are most commonly associated with substance and medication-induced bipolar disorder. Sedative/hypnotics are the least likely to be linked to this.

CHAPTER FOUR: DEPRESSIVE DISORDERS This chapter examines the different depressive disorders. It primarily includes major depressive disorder and dysthymia but also includes less commonly seen disorders, such as premenstrual dysphoric disorder and disruptive mood dysregulation disorder. As with many psychiatric classifications within the DSM-IV, there is discussion of substance or medication-induced depressive disorder and depression due to a medical condition.

DISRUPTIVE MOOD DYSREGULATION DISORDER (296.99) This is a new diagnosis for the DSM-V, which is seen as a persistently angry or irritable mood in childhood. There are frequent aggressive or angry outbursts with irritability and angry mood states between outbursts. This is a relatively common diagnosis among young patients already being treated for other psychiatric disorders. These symptoms might also be seen in conduct disorder, bipolar disorder, and oppositional defiant disorder, which need to be ruled out. The main symptom is an irritable or angry mood (with aggressive or verbal outbursts) occurring a minimum of three times a week. They must occur in different settings with unhappiness and irritability usually present. These outbursts are highly noticeable and can only be made in a child between the ages of 6 and 18 years, with onset occurring prior to ten years of age. This pattern of thinking and behavior must be present for a minimum of 12 months. The prevalence of the disorder (DMDD) is less than 1 percent of the general population and is disabling at home, in social situations, and in school, with children often avoiding playing with the affected child. Almost all children (92 percent) will have another psychiatric disorder with two-thirds of all kids having both an emotional and behavioral disorder. Common diagnoses include ADHD, major depressive disorder, anxiety disorders, and autism spectrum disorder.

While it can clinically seem like bipolar disorder, there is not true mania and no hypomania. The children who have DMDD are at a high risk of self-harm behaviors and suicidal behaviors. Common self-harm behaviors include skin picking, burning, cutting, pinching, carving, head banging, hitting, and biting behaviors. Many of the 4000 completed suicides in the US among children each year can be attributed to DMDD children who have died from suicide. The treatment of the disorder has not yet been established; however, drug therapy has been used as has psychotherapy and family therapy. One of the most effective strategies is familycentered therapy. Family therapy is preferred because family members spend more time with the child than any therapist can. They are treated with the goal of teaching parents and children how to interact with one another and how to handle angry outbursts. Medications, if used, are given to facilitate the therapeutic process and not to cure or truly manage the symptoms. Small groups of affected families can have group therapy to learn coping strategies. Parents are taught to respond more to good behavior than bad behavior and to use praise and rewards for good behavior.

MAJOR DEPRESSIVE DISORDER (296.20-296.36) This involves a great many patients who have low mood and a loss of interest in activities they previously enjoyed. It must persist for a minimum of two weeks for the diagnosis to be made. Other typical symptoms include irritability (especially in teens and children), weight changes, lack of motivation, low energy levels, sleep changes, lack of focus, and negative thinking. They often have thoughts of wanting to die, or thoughts of death and guilt can be prominent. At least one of these two symptoms must be present: 1. depressed mood, and 2. loss if interest or pleasure in things.

A total of five or more of the following symptoms must be present at the same two-week period of time: A. Depressed mood (which can be subjective or visible) B. Decreased interest in most previously-enjoyed activities C. Weight loss or weight gain of 5 percent of body weight within a month D. Visible psychomotor agitation or retardation nearly every day E. Loss of energy or fatigue F. Inappropriately guilty or worthless feelings G. Decreased ability to concentrate or indecisiveness H. Thoughts of death or suicidal thinking (not simply the fear of dying) The symptoms must cause significant distress or impairment in occupational, social, or other areas of functioning as they are occurring and they must not be secondary to the effects of a substance or to a medical condition. Things that must be ruled out include schizoaffective disorder, bipolar disorder, schizophrenia, or schizophreniform disorder. The disorder can be mild, moderate, or severe. Psychotic features are possible and the disease can be recurrent. A specifier is that of “peripartum onset,” in which the woman has the disorder after childbirth (occurring in 1 out of 500-1000 deliveries). Psychotic features in the postpartum state will have a family history of bipolar disorder or a personal history of bipolar disorder or depression. Other specifiers use catatonia, seasonal pattern, mood-congruent or mood-incongruent psychotic features, mixed features, atypical features, melancholic features, and anxious distress. The onset of major depressive disorder is usually in late adolescence with a high rate of firsttime incidence in the 18-20-year-old population. It can, however, occur at any age with a risk in women of 1.5-3 times that of men. Precursors to the disorder are having elevated degrees of negativity, life stressors, a difficult childhood, and concurrent life stressors. A genetic component is common with a 2-4 times risk if the person has a first-degree relative with depression.

The two most common treatments for major depressive disorder include antidepressants and individual psychotherapy. People tend to get better with a combination of both rather than one methodology alone. Different types of psychotherapy have the same rate of success; however, those undergoing cognitive-behavioral therapy have a much higher rate of dropping out. The attachment to the therapist is an important part of getting better as it increases brain integration and creates a healthier, more functional patient. Exercise seems to be as effective as antidepressant medication in mild to moderate depression. This means exercising at a fast walking pace for about 30 minutes a day five times weekly. It can be used in place of antidepressants in these patients. There is also not a great deal of difference in the relieving of depression between the different SSRI drugs for depression. Positive psychotherapy that focuses on positive experiences and socializing seems to enhance self-esteem and to decrease depressive symptoms. Having self-compassion (having empathy toward oneself) will reduce negative emotions, enhance optimism, and increase the degree of happiness the patient has.

DYSTHYMIA (300.4) This is also referred to as PDD or persistent depressive disorder. It is a chronic depression that is present on most days for a minimum of two years. The symptoms tend to be less severe than is seen in major depressive disorder (MDD) but some will have concurrent MDD with dysthymia— called double depression. About 30 percent of depressive patients will have chronic disease. One of the major differences between dysthymia and major depressive disorder is the presence of low self-esteem and social withdrawal being prominent in dysthymia and the presence of lack of sleep or lack of appetite in MDD.

Two of the criteria must be met for two years in order to have PDD (dysthymia). They must be present on most days for one year in kids and teens and two years in adults. There can be irritability in the mood state of this disorder. These are the criteria that can be in place: A. Sleep disturbance B. Appetite disturbance C. Low self-esteem D. Poor concentration E. Low energy or fatigue F. Hopeless feelings During the two years, the symptoms cannot abate for longer than two months and the patient may meet the requirement for MDD during that time (including the entire time). There cannot be hypomania or mania during this time (in which it would be called cyclothymic disorder). It cannot meet the criteria for delusional disorder schizophrenia, or schizoaffective disorder and it cannot be due to a medical disorder or drug abuse. If the patient meets the criteria for a major depressive episode the entire time, it is called major depressive disorder. If the MDD symptoms are present some of the time, it is called “double depression.” As for treatment, interpersonal psychology with medication works better than medicine alone just for chronic major depression but this is not the case for dysthymia. Psychotherapy is equally effective as SSRI treatment and has fewer side effects. Interpersonal psychotherapy works better than other therapies, such as cognitive behavioral therapy and behavioral therapy. Regardless of the treatment, long-term therapy is usually necessary. Couple’s therapy can also help with strengthening interpersonal relationships. Dysthymia is low-grade depression but, because it lasts a long period of time, it has a great impact on many areas of life functioning (social, occupational, and school). The patient may withdraw from many activities they enjoyed and may have a poor appetite and low energy levels. There may be a decline in school and work performance. Relationships can be strained or may dissolve. This is a diagnosis that is often ignored—to the detriment of the patient. The

risk for the disorder increases with having a first-degree relative with dysthymia.

PREMENSTRUAL DYSPHORIC DISORDER (625.4) This is referred to as PMDD. It is a relatively new diagnosis for the DSM-V and has been controversial as it medicalizes a possibly normal phenomenon for women. While it is a new diagnosis for the DSM-V, it has been recognized as a problem since the time of Hippocrates. It was previously called premenstrual tension and was believed to be caused by fluctuations in the sex hormones. It was also referred to as premenstrual syndrome and “late luteal phase dysphoric disorder.” It was officially called PMDD in the DSM-IV as it was recognized that it could also occur in the follicular phase. Some premenstrual symptoms are seen in up to 80 percent of women with 3-8 percent will meet the PMDD criteria. It tends to occur in the late luteal phase but can be seen in the follicular phase in a third of women. The average length of symptoms is six days, usually just before and in the first two days of the menstrual flow. Typical symptoms include despair, sadness, anxiety, panic attacks, anger, fatigue, and possibly suicidality. Food cravings, difficulty concentrating, and lack of interest in things can also be a part of this. There are somatic symptoms, such as bloating, headache, diffuse pain, and breast tenderness. The symptoms must resolve after menses begin. The new criteria in the DSM-V for PMDD include symptoms that begin in the last week of the menstrual cycle and that resolve shortly after menses start. At least five of 11 required symptoms must be present, including the following: A. Marked lability of mood B. Irritability or anger C. Depressed mood D. Anxiety and tension E. Decreased interest in usual activities F. Difficulty in concentration

G. Lethargy and marked lack of energy H. Marked change in appetite (such as binge eating or specific food cravings) I. Hypersomnia or insomnia J. Feeling overwhelmed or out of control K. Physical symptoms (breast tenderness, pain, bloating, and headache) One of the first four symptoms must be present with the addition of another four symptoms to make five total symptoms. These symptoms must be present for most menstrual cycles over the preceding year. They must cause significant distress or interference with daily activities in one or more areas of the person’s life. It cannot be caused by another psychiatric disorder but may be a comorbidity. It is desirable for the woman to chart her symptoms for two symptomatic cycles to make the diagnosis. Drugs, medications, or medical conditions may not explain the collection of symptoms. There have been many explanations proposed for women’s symptoms in PMDD. These include fluctuations in female hormones, some type of serotonin problem, “feminine psychological conflicts,” and maladaptive coping strategies. An imbalance in progesterone and estrogen have led to the idea that progesterone vaginal suppositories might help. The current idea is that hormonal fluctuations lead to an adverse interaction in the serotonin symptoms. SSRI drugs will help many of the symptoms of PMDD. There is a relationship between PMDD and major depressive disorder, anxiety disorders, and other psychiatric disorders. There are several treatment modalities suggested for PMDD, including certain birth control pills, progesterone suppositories, IUDs containing progesterone, GnRH analogues, diuretics, and NSAIDs. Buspirone has been successfully used for anxiety symptoms in PMDD. SSRIs can help; however, lithium and benzodiazepines have not been found to be helpful. There are many alternative therapies and homeopathic remedies for this problem that have not been well studied. Exercise and relaxation techniques, along with bright light therapy, have been found to be helpful for the depressive symptoms. Some women get better with cognitive behavioral therapy.

SUBSTANCE OR MEDICATION-INDUCED DEPRESSIVE DISORDER There are many substance-related disorders that can trigger mood symptoms, such as alcohol, tobacco, marijuana, caffeine, hallucinogens, inhalants, opiates, sedatives, and stimulants. Substance-induced mood disorders have been recognized since the 1950s, possibly earlier. There are two separate kinds of substance-induced mood disorders (according to the DSM-V). There are those consistent with the use of a substance and those linked to the actual abuse of a substance. Approximately 200 prescription drugs can cause depression, and the list includes common medications like proton pump inhibitors, beta-blockers, birth control pills and emergency contraceptives, anticonvulsants like gabapentin, corticosteroids like prednisone and even ibuprofen. There are a wide variety of possible causes of substance or mediation-induced depression. It can be secondary to abuse of an illicit substance or abuse of a prescription substance. Sometimes the use of the medication in prescribed doses contribute to depressed symptoms. Those symptoms typically seen include the following (and the list is not inclusive): A. Hypersomnia B. Listlessness C. Sadness D. Suicidal thoughts E. Social and emotional disengagement F. Hopelessness G. Irritability H. Fatigue The only way to make an accurate diagnosis is to consult with a psychiatrist and/or pharmacist who specialize in medication-induced symptomatology. There are many comorbidities including other mood disorders, such as bipolar disorder, major depressive disorder, and

dysthymia. Alcohol, medication, and substance abuse is depressing in and of itself. It is a disturbing cycle that often requires outside support in order to break it. There is no true cure for this. Psychotherapy may need to be ongoing in order to manage the symptoms and pharmacotherapy can help. The patient needs to accept their substance abuse problem and needs to recognize that it is causing their depressive symptoms. Drug treatment for this problem is complex and must be individualized to the patient and situation. Ideally, the patient should go through total detoxification lasting 2-4 weeks before any drug therapy can begin. The ideal drug for this type of depressive disorder, if not resolved after stopping the drug, is an antidepressant, such as an SSRI. Disulfiram (Antabuse), naltrexone, and other drugs have been successful in reducing relapses in alcohol abuse. There is a high rate of relapse with substance/medication induced depressive disorder and it is a lifelong problem. The presence of comorbid disorders worsens the prognosis. The disorder tends to be cyclic, with periods of relapse and remission. These patients are at a high risk for self-harm that comes in many different forms and is not seen in other depressive illnesses. Those who eat and exercise in a healthy manner will be less likely to suffer a relapse. Ongoing reliance on medical professionals will help encourage a healthier and more satisfying outlook.

DEPRESSIVE DISORDER DUE TO A MEDICAL CONDITION (293.83) Some medical conditions can directly lead to a depressed state. One classic medical condition that can cause this is hypothyroidism. In order to qualify as being a depressive disorder, it must adversely affect areas of functioning in the patient’s life. There can be mania or mixed features as well as depression in depressive disorders caused by medical conditions. There is a wide variety of medical conditions that can lead to a depressed state, including stroke, brain injury, and Huntington’s disease. Certain medical complications will also lead to depression but, as in Huntington’s disease, the depression starts at the beginning of the disease. It often heralds the disease or begins the initial psychiatric portion of the disease 67

process. For this reason, when faced with a depressed patient, non-neuropsychiatric medical conditions must be ruled out. Other comorbidities with depression secondary to a medical condition include Parkinson’s disease, which can affect up to 30 percent or more of cases of Parkinson’s disease. Huntington’s disease tends to have more depression in the beginning and less as the disease progresses; it affects more than half of all patients with the disease. It can be difficult to diagnose as the motor symptoms typically postdate the onset of depressive symptoms. Poststroke depression is common and increases the mortality rate after a stroke. Common features are sleep difficulties and social isolation. Other medical conditions typically associated with clinical depression include brain injury, Cushing’s disease, and multiple sclerosis. At least one report has found an association with sickle cell anemia. These patients tend to get better after undergoing cognitive behavioral therapy and other psychological interventions. Some patients require SSRI therapy.

KEY TAKEAWAYS •

Disruptive mood dysregulation disorder is a new diagnosis to the DSM-V and only occurs in children.

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Major depressive disorder can be diagnosed by meeting the criteria for a minimum of two weeks’ time.

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Major depressive disorder (and depressive disorders in general) do not have manic episodes.

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Dysthymia involves mainly low mood and low self-esteem lasting two years or more at a time.

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Premenstrual dysphoric disorder tends to affect women in the late luteal phase but can involve symptoms in the follicular phase.

QUIZ 1. Which is not one of the common psychiatric disorders that need to be ruled out in suspected cases of disruptive mood dysregulation disorder? a. Bipolar disorder b. Conduct disorder c. Schizophrenia d. Oppositional defiant disorder Answer: c. The major disorders that need to be ruled out include each of those listed; however, schizophrenia is not one of the disorders that mimic DMDD. 2.

About how often at a minimum should a child have aggressive outbursts in disruptive mood dysregulation disorder? a. Once per day b. Three times per week c. Once a week d. Once every two weeks Answer: b. A child with this disorder should have outbursts of aggression or verbal outburst a minimum of three times per week to qualify as having DMDD.

What is the age at which disruptive mood dysregulation disorder can be diagnosed? a. 2-10 years of age b. 5-15 years of age c. 8-20 years of age d. 6-18 years of age

Answer: d. The diagnosis can only be made between the ages of 6 and 18 years but it must have an age at onset prior to ten years of age. 4.

In major depressive disorder, there are not separate disorders for the different types but there are instead “specifiers.” Which is not considered a specifier of major depressive disorder? a. Of peripartum onset b. Seasonal pattern c. With manic features d. With mood-incongruent psychotic features Answer: c. Each of these is a possible specifier of major depressive disorder, except manic features, which would then be called bipolar disorder.

What does not increase the risk of major depression? a. Being middle-aged b. Being female c. Having concurrent life stressors d. Having first-degree relatives with depression Answer: a. While it can happen at any age, it will generally begin in adolescence and young adulthood.

What is the minimum amount of time a person must have symptoms in order to have persistent depressive disorder or dysthymia? a. Two weeks b. Six months c. One year d. Two years

Answer: d. The symptoms must be present on most days for two years to qualify as having dysthymia or PDD. 7.

Which depressive disorder is new to the DSM-V and wasn’t present in previous manuals? a. Premenstrual dysphoric disorder b. Persistent depressive disorder c. Postpartum depression d. Disruptive mood dysregulation disorder Answer: d. DMDD is new to the DSM-V. PDD has been in other manuals and postpartum depression exists only as a specifier. DMDD is a new disorder that has been created to include children with angry or irritable mood and angry or aggressive outbursts.

Which is not one of the key symptoms in PMDD that must be met as part of the criteria for PMDD? a. Marked lability of mood b. Insomnia or hypersomnia c. Irritability or anger d. Depressed mood Answer: b. The diagnosis of PMDD is somewhat complex. One of four symptoms must be met, including those listed (plus anxiety and tension), with any of the other symptoms to make five of 11 total symptoms.

Which drug is least likely to help women who have PMDD? a. NSAIDs b. Buspirone c. Benzodiazepines

d. SSRIs Answer: c. Each of these has been found to be helpful in treating PMDD; however, benzodiazepines have not been found to be particularly helpful. 10.

Which disorder is least likely to be associated with a depressed state? a. Cerebrovascular accident b. Parkinson’s disease c. Brain injury d. Iron deficiency anemia Answer: d. While patients with iron deficiency anemia have fatigue they don’t generally have depression, while the other disorders are highly linked to medically-related depression.

CHAPTER FIVE: ANXIETY DISORDERS There are many mental illnesses that fall under this category. Some primarily affect children, such as separation anxiety. Some are very specific, such as specific phobia, agoraphobia, and social anxiety disorder. Others have no obvious focus, including panic disorder and generalized anxiety disorder. These and anxiety disorders that are due to substances and medical conditions are covered in detail in this chapter.

SEPARATION ANXIETY DISORDER (309.21) Separation anxiety disorder is a diagnosis given to individuals who have an unusually strong fear or anxiety about separating from people they feel a strong attachment to. This occurs when the distress connected to separation is out of the ordinary for the person’s developmental age. It makes it difficult for children to be alone or to go outside of the home for school or recreational purposes. It can affect older individuals from leading an independent life away from their family of origin. The main symptoms are the following: A. Having an unusual degree of distress around being separated from an attachment figure. B. Having excessive fears that harm will happen to the attachment figure. C. Worry that an unexpected occurrence will separate them from an attachment figure. D. Inability to leave an attachment figure. E. Extraordinary fear of being alone. F. Frequent nightmares around separation.

G. Sleep anxiety when asked to sleep alone. H. Physical complaints when separation is threatened. Children who have this are very clingy and are unable to tolerate being alone. They cannot sleep when parents are away and fear for their parents’ safety. They may have difficulty going to school and keep track of when their parents are going to come home. They have frequent abdominal pain and vomiting or other physical symptoms. Adults will have similar symptoms related to their partner or parent. They often cannot live independently. The major criterion is having extraordinary or excessive fear about separation from those they are attached to. This involves having at least three of the following: A. Excessive distress when anticipating or experiencing separation from an attachment figure. B. Worry about losing an attachment figure to injury, illness, or disasters. C. Excessive worry about an unexpected event that causes separation from an attachment figure. D. Reluctance or refusal to leave home and go to school, work, or social activities. E. Fear of being alone without an attachment figure. F. Inability to sleep alone without an attachment figure nearby. G. Nightmares related to being separated from an attachment figure. H. Physical symptoms when separated or anticipated to be separated from an attachment figure. The symptoms must last at least four weeks in children and adolescents or six months in adults. They must cause distress or impairment in several life areas. They cannot be explained by another anxiety disorder or other mental disorder like autism spectrum disorder, illness anxiety disorder, or psychotic disorders. Separation anxiety is normal in the ages of 8 to 15 months. It is the most common anxiety disorder in kids under 12 years of age, with an incidence of 4 percent in children and 6 percent in adults. It was originally seen as only occurring in children but is seen in adults with 77 76

percent of adults with the condition developing the disorder in adulthood rather than childhood. The anxiety can be from a relationship with a parent, adult child, or relationship partner and affects all areas of life. There is a high incidence of comorbidity with another anxiety disorder or a mood disorder. Medications and psychotherapy are used to treat separation anxiety disorder. Art therapy is used in children as are cognitive behavioral therapy and exposure therapy. Exposure is increased gradually until they have a greater tolerance to separate from the attachment figure. Parents can be trained to help their children. Psychotherapy can help develop secure attachments.

SELECTIVE MUTISM (312.23) Selective mutism involves the inability to speak under certain circumstances in a child. They may be able to speak easily at home but, upon starting school or when asked to speak in public, they cannot speak. This is believed to be a type of social phobia usually diagnosed around the age of five when a child starts school. The disorder must last a month before it can be diagnosed according to the DSM-V. It often has a detrimental effect on the individual’s school and social life. It cannot be due to a psychotic disorder or stuttering. Other behaviors are temper tantrums, shyness, social isolation, and clingy behavior. The diagnosis is usually made when the parents recognize that the child will talk at home but refuses to speak in social situations—even at family gatherings and on holiday outings. The teacher recognize a child who hasn’t spoken since starting school for a month or more. The first thing that should be done is a physical examination with psychoeducational testing. A developmental exam should also be done to include a speech and language evaluation. There is no tried and true drug therapy for selective mutism. The family needs to see a child therapist who uses behavioral strategies to help change the child’s behavior. The goal is for the child to learn speaking-related behaviors through positive reinforcement. Cognitive-behavioral therapy can help identify anxious thinking that may be causing the child to be mute. There are

other therapies that can help as well. The most commonly used drugs for selective mutism are the SSRI drugs, despite not being approved for treating this disorder. The child who gets diagnosed early and gets treated will respond better and will have a better prognosis. The longer a child remains mute, the longer it becomes conditioned in the affected child. The prognosis is overall excellent with complete recovery if treated.

SPECIFIC PHOBIA (300.29) A specific phobia is one of the more common diagnoses under the category of anxiety disorders in the DSM-V. It is a diagnosis given to people who have an intense and irrational fear when exposed to specific situations or objects. There are many different things that a person can have a phobia to. Phobias can be persistent and can cause the subject to avoid the situation or object connected to the fear. There can be severe distress related to the feared object or situation. Specific phobias affect nearly 20 million US adults with women affected at a 2:1 ratio compared to men. Most specific phobias develop during childhood but it can begin at any age, usually connected to a traumatic experience. There can be familial influences or genetic factors that play into getting the disorder. The main symptom is an intense fear related to the anticipation of the presence of the stimulus. Things that can be seen include palpitations, nausea, dizziness, shaking, sweating, dyspnea, and abdominal upset. Avoidance behavior can also be seen. The diagnosis is made when the following exist: A. There is a specific object or situation that there is a persistent fear that the patient has a specific fear or unreasonable degree of anxiety toward. B. The exposure results in anxiety that is obvious, such as a panic attack, clinging behavior, crying, or freezing. C. The adult with the disorder recognizes that the fear is irrational (but not a child). D. There is avoidance behavior in which the person stays away from that which provokes the anxious response. 78

E. The phobic response interferes with the individual’s activities of daily living or causes significant distress. F. The symptoms last at least six months. G. The symptoms cannot be explained by OCD or PTSD. Types of simple phobias include the following as they often fit into a specific category: A. Natural phobias—heights, deep water, or germs B. Animal phobias—to snakes, spiders, dogs, and other animals C. Situational phobias—such as visiting the dentist or flying in an airplane D. Bodily phobias—such as having shots or seeing blood E. Other—such as choking or vomiting Examples of complex phobias are more debilitating and have a greater effect on the individual’s life. These involve the following complex situations: A. Social phobia—fear of most social situations B. Agoraphobia—fear of open spaces or certain places There is no single cause of a simple phobia but there are a number of potential contributing factors that are seen as possible causes. These include having a traumatic experience that later causes a phobia (like being bitten by a dog at a young age), learned behavior (learned by a relative who has the same phobia), genetics (with genes unsubstantiated as yet), a fear response that develops into a phobia, and being in a high stress situation. While having a specific phobia is troubling, it does not have a great impact on the individual’s life as is usually involves things that the person isn’t in contact with on a daily basis. Complex phobias have a bigger impact on the patient’s life as the situations are more pervasive. Complex phobias can affect individuals on a daily basis, causing extreme distress and anxiety. Sufferers will go out of their way to avoid the situation or perceived threat in their lives. There is no single form of treatment that will work and most people don’t request treatment because they rarely encounter the object of their phobia. If treatment is necessary, cognitive 79

behavioral therapy is an option, which includes a gradual exposure to the stimulus. Medications that can be used include anti-anxiety beta blockers like propranolol, benzodiazepines, and SSRI drugs. Hypnotherapy is not standard but has been found to be helpful to some individuals. Relaxation and mindfulness techniques, along with group therapy, are also helpful.

SOCIAL ANXIETY DISORDER (300.23) This is also known as social phobia and involves anxiety and discomfort in social situations with a worry about being embarrassed and judged by other people. This will be manifested as anxiety and fear with autonomic arousal, such as apnea, diaphoresis, tremors, nausea, and tachycardia. This will range in severity from mild to very severe and disabling. The discomfort can include eating in front of others, using a public bathroom, and being in social situations. It can lead to social isolation and a lack of development of social skills. There are ten diagnostic criteria, including the following: •

Fear/anxiety related to social situations, where the person feels observed, noticed, or scrutinized. In kids, it must be related to social situations with peers.

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The individual will fear that their anxiety will be displayed, causing social isolation.

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Social interactions will provoke distress in the individual consistently.

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Social situations are avoided, if possible.

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Fear and anxiety will be disproportionate to the situation they are in.

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The symptoms last for a minimum of six months.

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The symptoms cause impairment in more than one domain of function.

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The disorder is not related to a medication or medical disorder.

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The disorder cannot be explained by a mental disorder.

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If the patient has a physical defect causing social anxiety, the anxiety must be unrelated or out of proportion to the situation.

There is a specifier that includes social anxiety related to a specific performance situation. The onset usually happens at a median age of 13, with most starting the disorder between 8-15 years. The onset can be slow or sudden. The prevalence of the disorder is about 7 percent. The DSM-V indicates that the individual has a temperament characterized by fear of social evaluation and being uninhibited. Peer abuse and other child abuse has been linked to social phobia and there appears to be both genetic and learned behaviors involved. Obesity is a risk factors in teens who experience rejection by peers. Common comorbidities include anxiety disorders, depression, and substance abuse disorders. The treatment of social anxiety disorder uses cognitive behavioral therapy, which can replace anxious feelings with more realistic relaxed feelings. Systematic desensitization is a part of this process and will help patients tolerate more anxiety-provoking situations. If not treated, the quality of life can be adversely affected because of social isolation and withdrawal. Things that must be ruled out include shyness and introversion as a personality characteristic, agoraphobia, generalized anxiety disorder (GAD), PTSD, and specific phobias. Depression can be the result of having social phobia but is a different disorder altogether. Body dysmorphic disorder can result in social discomfort but has a different etiology. Delusional disorder can result in social withdrawal but has a different etiology. Autism spectrum disorder results in withdrawal from social activity but has a different etiology. Personality disorders can result in social awkwardness but is part of the personality and not a specific diagnosis. People may have a medical condition that makes them self-conscious but this also is not a specific diagnosis.

PANIC DISORDER (300.01) Panic attacks lead to panic disorder. A panic attack is the sudden surge of intense discomfort or fear that peaks within a few minutes. The attacks need to be recurrent to qualify for the disorder. The panic interferes with daily living and can result in avoiding social or public 81

situations. The patients try to avoid becoming embarrassed by their behavior. The most prominent criterion is the presence or recurrent unexpected attacks. They cannot be predicted and come out of the blue. They can occur during a time of existing anxiety or during a previously calm state—even when sleeping. Typical signs include an accelerated heart rate, pounding heart beats, chest pain, trembling, dyspnea, sweating, nausea, dizziness, choking feelings, detached feelings, chills or heat sensations, numbness, fear of losing control, and/or fear of dying. There is persistent fear over having another attack. The fear over having another attack involves changing habits in order to avoid having a panic attack in public, such as avoiding specific places where panic attacks have occurred. Missing school and work may also be a problem. Social isolation can lead to sadness, depression, and problems with interpersonal relationships. The patient may have concerns about their health as the symptoms can mimic a real cardiac or neurological problem. Panic disorder is the most common cause of noncardiac chest pain. The prevalence of panic disorder is about 2-3 percent in adults and adolescents. Risk factors include having an anxious temperament, child abuse, and heredity (with a twin-twin concordance rate of 30-40 percent). No specific gene has been identified. People with depression, anxiety, or bipolar disorder have an increased risk of panic disorder as well. There are many medications that exist to decrease the symptomatology of panic disorder but they are much more effective with therapy. Dialectical Behavioral Therapy or DBT seems to help people who struggle overcoming anxiety and panic. Group therapy can help patients with similar symptoms. Children with panic disorder need to have family involvement to teach the family about the problem and how to address it.

SPECIFIED PANIC ATTACK Panic attacks can occur in other types of anxiety disorders. There are three types of panic attacks that will be discussed. As mentioned, panic attacks are sudden and extreme feelings of discomfort to fear that lasts for a distinct time period. It peaks within minutes and then 82

subsides. The diagnosis is made by having four of the symptoms listed here: •

Palpitations and/or sensation of heart pounding

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Sweating

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Shaking or trembling

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Dyspnea or feeling smothered

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Choking sensation

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Chest pain

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Nausea

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Dizziness or lightheadedness

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Heat or cold sensations

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Numbness or tingling

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Derealization or depersonalization

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Fear of dying

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Fear of losing control

When a patient has fewer than four symptoms, it is called a limited-symptom panic attack with typical symptoms being hyperventilation and shortness of breath. Patients perceive danger as occurring at the present time and have intense terror or fear. This is different from a typical fear reaction as there are a lot of physical symptoms. There are two other types of panic attacks: 1) expected (cued) panic attack; and 2) unexpected (un-cued) panic attack. An un-cued panic attack will come out of the blue without an identifiable trigger. There may be underlying stress that triggers them. In order to have panic disorder, the attacks have to be uncued. Expected or cued panic attacks have an obvious trigger that the patient usually knows about. This type of attack is commonly seen in social anxiety disorder, specific phobia, and agoraphobia.

GENERALIZED ANXIETY DISORDER (300.02) People with generalized anxiety disorder or GAD will worry about a number of things in their life. They may be anxious just trying to get through activities of daily living, even when there is nothing to worry about. This constant worry and anxiety make it difficult to get through the day and perform normal daily tasks. Difficulty sleeping and poor concentration can be problems so that things like reading can be very difficult. The key feature of GAD is constant and unsubstantiated worry. Themes involved in worrying include work, money, health, and family. The worry will disrupt social activities and other activities of daily living. There are physical symptoms as well. These include fatigue, muscle tension, GI problems, irritability, restlessness, sleep problems, and edginess. The symptoms will overlap those of depression or somatic disorders. Nearly half of these patients will be misdiagnosed because of their many somatic complaints. To make a diagnosis of GAD, all of the following features must be present: •

Excessive worry and anxiety for six months

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Difficulty controlling the worry

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Having at least three of the following symptoms: Restlessness, fatigue, difficulty concentrating, irritability, sleep disturbance, muscle tension

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The symptoms must cause impairment in many areas of functioning or great distress

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The problem is not due to a substance or medical condition

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The problem cannot be explained by another mental illness

The prevalence of GAD in the general population over a lifetime is 4-6 percent with the symptoms being seen in twice as many females as males. The most common age at first diagnosis is 45-59 years, rarely being seen in those older than 60. Untreated, it is a chronic disease and only 40 percent of GAD patients are adequately treated.

It is seen with a number of comorbid psychiatric conditions, including other anxiety disorders, major depression, bipolar disorder, and substance abuse disorder. Since GAD shares several similarities to major depression, some have suggested it become a mood disorder. When the two coexist, there is an increased risk of disability and suicide. GAD is managed with medications, psychotherapy, or both. Cognitive behavioral therapy is particularly helpful by changing patterns of thinking, behaving, and reacting to life stressors. Medications commonly used include SSRIs (which aren’t addictive) and anxiolytics (which are addictive). Because of the addictive potential, the most commonly-used drug classification is the SSRI drugs.

AGORAPHOBIA (300.22) Agoraphobia is a diagnosis given to those who have an extraordinary fear of public places— often seeing such places as too open or too crowded. Patients will have panic and distress that disrupt everyday living. Patients are said to have a fear of “open spaces” and struggle to leave their home, use public transportation, and go shopping. Simply entering a public place or thinking about this will cause excessive distress and physical symptoms, like tachycardia, dyspnea, and excessive sweating. It usually starts at 20-30 years of age and is seen more commonly in women. The main symptoms of agoraphobia include the following: A. Becoming detached or isolated B. Fear of being alone C. Increased dependence on others D. Fear of losing control in public E. Avoiding spaces that can’t be gotten out of F. Inability to leave the home G. Physical symptoms like palpitations, diaphoresis, nausea, diarrhea, dizziness, chest pain, or trembling

In order to make the diagnosis of agoraphobia, the following criteria need to be met: 1. Fear of crowds, open spaces, or public transportation (at least two situations) 2. Marked anxiety/panic when exposed to the phobic area 3.

Recognition that the fear is inappropriate

Avoidance of areas that make the person uncomfortable

Symptoms for a minimum of six months

No other underlying pathology

There are a number of risk factors and possible causes of agoraphobia. These may contribute to having the disorder: •

Hormonal or chemical imbalance

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Specific personality types

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Excessively controlling family members

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Lack of spatial awareness

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Childhood trauma

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Impairment of the fight-or-flight response

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Prior mental illness

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Recent traumatic event

The agoraphobia can develop out of fear of a specific place in which the patient had a panic attack and then it becomes generalized. There are many comorbid diseases, such as OCD, GAD, social phobia, dysthymia, major depression, or panic disorder. Panic disorder is the most common comorbid condition with about a third of panic-disordered patients developing agoraphobia.

Things that trigger agoraphobia include driving, shopping in busy places, being alone outside the home, and using public transportation. The patient will often stick to a certain route or schedule around driving places or may only go to certain stores. They often keep medication athand or hang onto their cell phone so they can call for help if uncomfortable. The treatment of agoraphobia includes learning self-help techniques, learning how to manage stress through exercise and other lifestyle choices, cognitive behavioral therapy, and medications. Common medications used are SSRIs, benzodiazepines, and beta-blockers. Usually, a combination of therapy and medications offer the best relief. Systematic desensitization as is used for other phobias can help.

SUBSTANCE/MEDICATION-INDUCED ANXIETY DISORDER (292.8) As you have seen, most of the other disorders under anxiety disorders have the criterion that the symptoms are not secondary to a medication or substance. In this case, there must be a temporal relationship between taking the drug or medication and the development of anxious symptomatology. The symptoms include fear and physical symptoms with the fear being unrelated to a specific cause or threat. The symptoms occur while under the influence of a drug or when withdrawing from a drug. The symptoms can start up to four weeks after stopping a drug and can continue for up to six months. Symptoms can last for years after stopping benzodiazepines, alcohol, some antidepressants, and opioids. Drugs that can cause anxiety include cannabis, alcohol, amphetamines, hallucinogens, PCP, and intoxicants. Withdrawal from cocaine, alcohol, illicit opioids, caffeine, and nicotine can also cause anxiety symptoms. Many prescription and OTC drugs can cause anxiety, including antibiotics (especially fluoroquinolones), anticholinergic drugs, anesthetic drugs, antihypertensives, antihistamines, bronchodilators, cough/cold medicine, insulin, hypoglycemics, and anticonvulsants. All psychotropic drugs have the ability to cause anxiety. The symptoms may not include obsessive-compulsive symptoms and must show up within a month of starting or stopping a drug. It must not be secondary to a known anxiety disorder or

to delirium. The causative drug is not used as a specifier. The duration of symptoms depends on the half-life of the drug in question.

ANXIETY DUE TO A MEDICAL CONDITION (293.84) Anxiety disorders are basically excessive reactions to stress. When a person has a medical disorder, they have an automatic source of anxiety. There may be an unexpected threat or an upcoming future threat that leads to anxious symptoms. Anxiety due to a medical condition will have an anxious mood as the most prominent symptom. The patient will have all of the typical symptoms related to an anxiety attack with dyspnea, dizziness, diaphoresis, heart palpitations, and muscle tension. The patient may feel a sense of impending doom or the feeling that something catastrophic will happen. There may be panic-related symptoms. There may be OCD symptoms as well. In order to make the diagnosis, there must be some evidence that the anxious symptoms are directly related to a medical condition. This means doing a history, physical examination, and lab tests to establish the connection. It cannot be better explained by having another anxiety disorder and should cause an impairment in at least one area of life functioning. Typical disorders that can cause this problem include hypothyroidism, hypoglycemia, hyperthyroidism, and hyperadrenalism. Heart problems can contribute to this disorder as can breathing disorders. Certain neurological conditions, like a brain tumor or encephalitis, can trigger anxiety. The differential diagnosis includes delirium, which can lead to an anxious mood. Dementia, on the other hand, can be a medical condition causing anxiety. The use of a drug or drug withdrawal may not be the cause of the problem and must be considered in the differential. There can be a dual diagnosis of substance use and a medical condition causing the anxiety. The treatment involves treating the underlying condition, medically treating the anxiety with anxiolytics, tricyclic antidepressants, or SSRIs, and mental health counseling or therapy. Beta blockers can decrease some of the physical symptoms in heart conditions. Cognitive behavioral therapy will help decrease symptoms that last longer than a brief period of time. 88

KEY TAKEAWAYS •

Certain anxiety disorders like selective mutism primarily affect children.

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Separation anxiety disorder is actually more prevalent in adults than it is in children.

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Panic attacks that become repetitive will become panic disorder.

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A third of panic disorder patients will develop agoraphobia later on.

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Generalized anxiety disorder involves excessive worry that is out of proportion to normal states.

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There can be substance-related and medical condition-related anxiety states.

Quiz 1. How long do the symptoms of separation anxiety disorder have to last if the diagnosis is to be made in a child or adolescent? a. 2 weeks b. 4 weeks c. 6 months d. 1 year Answer: b. In children and adolescents, the symptoms need to be present for a minimum of four weeks to make the diagnosis of separation anxiety disorder. 2.

What is true of adults with separation anxiety disorder? a. It is rarer in adults than in children b. It generally starts in childhood and progresses to adulthood c. It is generally associated with difficulty attaining an independent life. d. It is usually associated with elderly patients. Answer: c. Adults with the disorder have difficulty attaining an independent life. Most cases start in adulthood and it affects adults more than children. It can be associated with a romantic partner or with an adult child.

How long must the symptoms last in adulthood separation anxiety disorder to make the diagnosis? a. 2 weeks b. 4 weeks c. 3 months d. 6 months

Answer: d. The symptoms must last a minimum of six months in adults diagnosed with separation anxiety disorder, according to the DSM-V. 4.

What is not a typical symptom involved in having a specific phobia? a. Palpitations b. Dizziness c. Nausea d. Headache Answer: d. The individual with a specific phobia will have palpitations, dizziness, upset stomach, nausea, dyspnea, and tremor. They tend not to have a headache.

What does the DSM-V not recognize as a simple phobia but is instead a complex phobia? a. Social phobia b. Situational phobia c. Natural phobia d. Bodily phobia Answer: a. Social phobia is a complex phobia having a greater impact on the person’s life when compared to the other phobias, which are simple phobias.

Which type of drug is least successful for specific simple phobias? a. Beta blockers b. Mood stabilizers c. Benzodiazepines d. SSRI drugs Answer: b. Each of these drugs can be helpful in controlling specific simple phobias except for mood stabilizers, which are generally not used.

Which is least likely to be a risk factor for panic disorder? a. Having schizotypal anxiety disorder b. Having an anxious temperament c. Suffering from bipolar disorder d. Having a history of depression Answer: a. Each of these is a risk factor for panic disorder except for having schizotypal personality disorder. Anxiety and child abuse can be other risk factors.

What is not a typical symptom associated with a panic attack? a. Chest pain b. Fear of dying c. Headaches d. Derealization Answer: c. There are many different symptoms of panic attacks; however, headaches are not necessarily seen in this phenomenon.

What is the major feature seen in generalized anxiety disorder? a. Somatic complaints b. Chronic worry c. Sleep deficits d. Poor concentration Answer: b. While each of these can be seen in generalized anxiety disorder, the major feature seen is chronic unsubstantiated worry.

10.

The patient with agoraphobia will have certain comorbidities possible. What disorder is the most common comorbidity with this disorder? a. Generalized anxiety disorder b. Major depression c. Dysthymia d. Panic disorder Answer: d. The comorbidity with panic disorder is so great that a third of panic disorder patients will develop agoraphobia.

CHAPTER SIX: OBSESSIVE COMPULSIVE AND RELATED DISORDERS This chapter covers obsessive compulsive disorder (OCD) and related disorders. The related disorders have a wide range of symptoms and causes. They include things like body dysmorphic disorder, hoarding disorder, excoriation disorder, and trichotillomania. There are categories for OCD that is related to substance use and to a medical condition.

OBSESSIVE COMPULSIVE DISORDER (300.3) This is also referred to as OCD. It involves having intrusive images, thoughts, or impulses that cause a great degree of emotional distress. The distress can be anxious distress; however, disgust and guilt can also be a part of the emotional response. In order to cope with the emotional distress, the patient will perform some type of ritual (overt or covert). The ritual will reduce the emotional response intensity and decrease the likelihood of acting on the image or thought. This is called “thought-action fusion.” The patient will usually know the futility of doing the ritual but cannot stop engaging in the behavior. According to the DSM-V, the patient can have obsessions and/or compulsions. There are those who just have obsessions and are referred to as “pure obsessionals.” Obsessions have to do with aggression, harm, symmetry, and cleanliness. Patients will respond with rituals, such as cleaning, arranging, and counting. The definition of obsessions includes recurrent and persistent impulses, images, and thoughts that are intrusive and cause distress. They cannot be exaggerations of real life problems but must be out of the ordinary. The person will attempt to neutralize, suppress or ignore the obsession without success. The person realizes that these are not delusional but are just made

up in their own mind. Compulsions are the mental acts or repetitive behaviors that the individual feels they must do to quell the thoughts related to an obsession. The behaviors or mental acts tend to reduce the patient’s stress and will decrease the tendency to carry out the obsession. They may or may not be directly related to the obsession, as in compulsive washing in order to stave off contamination. The symptoms seen in OCD cannot be explained by another mental illness, substance use, or a medical condition. The first medical line of treatment involves SSRI therapy, which reduces obsessions and associated anxiety. Cognitive-behavioral therapy can be used, which consists of exposure and response prevention methods. Psycho-education and relaxation training (PRT) is used to treat children with the disorder. Behavior therapy and family-based therapy will decrease OCD in children; however, individual CBT does not seem to be helpful in these kids. Family members often feel confused and angry about these symptoms, especially in kids, so parent management therapy along with CBT will reduce the symptomatology better than CBT alone. Deep brain stimulation will improve some aspects of the disorder. Without treatment, the patient can have a severely affected quality of life in many life areas. The compulsions are often time-consuming and will impact the level of functioning. Severely affected patients will spend hours a day doing their rituals and will be perceived as eccentric or odd. The patient will be reluctant to get treatment as they feel their behavior is shameful or embarrassing. Family members suffer, which is why family-focused cognitive behavioral therapy (FCBT) will usually be more beneficial than individual CBT.

BODY DYSMORPHIC DISORDER (300.7) This is also referred to as BDD. It is a DSM-V diagnoses that involves having anxiety or distress due to a perceived physical anomaly, such as a scar, a certain physical feature, or the shape/size of a body part. While most individuals will have a degree of dissatisfaction with their appearance at times, people with BDD will have ongoing and intrusive thoughts about their

flaw, which may be exceedingly minor and will be something others are not concerned with or don’t notice. It is different from distorted body image seen in eating disorders, which is more related to total body mass rather than a specific area. Individuals with an eating disorder may be preoccupied with certain areas of their body that they don’t like, but the focus is regarding the mass of the area as it relates to the total body mass. BDD patients will be concerned about body mass but only related to certain things like a lack of muscle definition in an area or in the entire body. There is self-consciousness, distress, and avoidance of social situations and/or intimacy because of their perceptions, which lead to depression, social isolation, and suicidality. The patient will often undergo unnecessary cosmetic surgery, skin procedures, or dental procedures to correct the perceived flaw. Unfortunately, they are rarely satisfied with the results because of ongoing perceptual problems. Some believe that this disorder is actually part of OCD; however, the DSM-V classifies this as a discrete disorder under the umbrella of OCD-related disorders. There are four diagnostic criteria for body dysmorphic disorder with four different specifiers. The major criteria include the following: 1. Being preoccupied with a physical feature they perceive as flawed, which is not concerning to others. 2. Having repetitive behavior focusing on the perceived anomaly, like examining oneself in the mirror or trying to hide the flaw. They constantly seek reassurance about their appearance but aren’t satisfied with the responses they get. 3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The appearance preoccupations are not restricted to concerns with body fat or weight and the patient does not meet the criteria for an eating disorder.

Specifiers include the following: A. Dysmorphia—obsession regarding musculature, in which there is a fixation about one or more muscle groups. B. Good or fair insight—the patient will be able to be distracted from their preoccupation and have a good prognosis. C. Poor insight with the patient needing constant reassurance with brief moments of insight. D. Absent insight or delusional—the patient is convinced of their defect and will not respond to surgical intervention or reassurance. The average age of onset of BDD is 16 years; although it is often seen in kids who develop the disorder at around puberty (aged 12-13 years). The prevalence of body dysmorphic disorder in the US is about 2.5 percent in males and 2.2 percent in females. Risk factors for BDD are child abuse, a history of sexual trauma, bullying, and hormonal imbalances. The main comorbidities are depression, OCD, and substance abuse. They may use substances to self-medicate and may be so depressed as to be suicidal. While BDD is chronic, it responds favorably to treatment. CBT is effective as it challenges the patient’s irrational beliefs and perceptions regarding their bodily features. They are somewhat resistant to starting treatment as they don’t see their beliefs as irrational. SSRIs are a good first-line therapy for the treatment of this disorder. There are several things to rule out as part of diagnosing BDD. These include OCD, somatic anxiety, eating disorders, major depressive disorder, psychotic disorders, and anxiety disorders. There are several rarer disorders that can mimic BDD, such as gender dysmorphia, body identity integrity disorder, dysmorphic concern, and olfactory reference syndrome.

HOARDING DISORDER (300.3) Hoarding disorder is a diagnosis given to persons who have distress over discarding any items and who excessively save most items. They cannot part with anything so that they have excessive clutter to such a degree that they create safety and health risks in their home. It is a bigger thing than clutter and collecting. These patients have roomfuls of stuff that have very little value and have little room to maneuver in their home. Tables, sinks, and even chairs/couches are unusable. They often do not invite guests over and people do not feel comfortable in the hoarder’s home. Their home is often a safety issue. Typical symptoms include the following: A. Severe anxiety over the idea of discarding possessions. B. Inability to discard possessions and things. C. Having limited living space in their home. D. Using common areas of the home as storage spaces. E. Loneliness F. Social isolation and withdrawal G. Depression H. Disorganization I. Fear or embarrassment about having visitors to their home J. Being indecisive as to where to put things The DSM-V diagnostic criteria include the following: A. Persistence in having a difficulty parting with possessions that have negligible value. B. Distress associated with getting rid of items and/or perceiving the need to save items. C. Distress resulting in the accumulation of possessions that clutter the home excessively. D. The hoarding causes distress and/or impairment in several areas of life functioning.

E. The disorder is not attributable to another medical condition, such as brain injury or stroke. F. The hoarding cannot be explained by symptoms of another mental disorder. They often buy things that are not necessary and that they don’t have the space for. The hoarder may have good insight or poor insight into their problem. About 80-90 percent of these patients engage in excessive shopping and buy unnecessary items. The disease affects about 2-6 percent of individuals, usually common in older adults, although it starts to cause impairment in the patient’s 30s. About 20 percent of patients will have true OCD and are likely to hoard strange things, like trash, nails, hair, and feces. About 57 percent will have depression, 29 percent will have social phobia, and 28 percent will have ADHD. People with hoarding disorder generally don’t think they have a serious problem and will only go for treatment when they are pushed by family members or at risk of eviction. As hoarding can create risks to health, the goal is to attain reduction in physical harm. Treatment often involves a team of nurses, psychologists, and social workers as well as support groups, psychotherapy, and medications. CBT given to a group of individuals with a hoarding problem to decrease the symptoms. Hoarders who do not get treated have limited mobility and a low quality of life. The stuff takes over their living space and their lives. They live a lonely existence with decreased interaction between themselves and other people. Things that tend to get saved include magazines, newspapers, clothing, books, bags, and paperwork. They have health problems related to unsanitary conditions and unstable structures of their homes. They often violate fire and safety codes so they run the risk of being evicted.

TRICHOTILLOMANIA (312.39) This is the DSM-V diagnosis given to people who recurrently pull their hair out. They feel compelled to pull out hair from their head or body, resulting in significant impairment. It is classified as a body-focused repetitive behavior. It is related to conditions of self-grooming,

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which includes picking, pulling, scraping, or biting the hair, skin, or nails, resulting in damage to body areas. The person with trichotillomania has the overwhelming urge to pull hair out of their eyelashes, eyebrows, and head. They have tension that can only be relieved by pulling hair out. Some do the behavior directly because of stress, while others have the subconscious urge to do this behavior. The ratio of females to males with this disorder is 10:1 with prevalence of about 1-2 percent of Americans. It usually starts at puberty or just past puberty at 12-13 years. Typical symptoms include the following: A. Constant twist or pulling hair B. Bald patches on the head or eyebrows C. Uneven appearance to the hair D. Denying that hair pulling is taking place E. Bowel obstruction from hair swallowing F. Tension preceding hair pulling G. Other self-injurious behaviors H. Poor self-image I. Feeling anxious, sad or depressed While most people pull their hair from their scalps, some patients with trichotillomania will pull hair from their eyelashes, eyebrows, beard, genital area, or moustache. The diagnosis is made using these diagnostic criteria: A. Recurrent pulling out of hair, resulting in hair loss. B. Having repeated attempts to reduce or stop hair pulling. C. Having extreme distress or impairment from the behavior. D. Hair pulling is not secondary to another medical condition. E. Hair pulling cannot be explained by another mental disorder.

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These people experience increased stress in their everyday lives that is compounded by embarrassment over their behavior that, in turn, affects their activities of daily living. They may fear social situations because of their appearance or inability to control their behavior in public. They do, however, manage to avoid doing the behaviors in public except with close family members. Hair pulling can extend to pulling hair from toys or pets. Swallowing hair is not uncommon. There is no single cause to trichotillomania but a number of factors may contribute to the onset of the disorder. Scientists have identified individuals with some type of genetic predisposition to the disorder and there is an increased risk of trichotillomania in people with OCD or who have first-degree relatives with OCD. Other factors that may play a role in getting the disorder include chemical imbalances in the brain, hormonal changes in puberty, poor coping skills, or similar factors that lead to self-injurious behavior. Comorbidities with trichotillomania include major depressive disorder, excoriation disorder, and obsessive-compulsive disorder. About a third of all patients will have some type of anxiety disorder, while 1 in 5 will also have a substance use disorder. If the hair pulling or manipulation is intended to make the individual appear better (according to them), it is not trichotillomania. Some OCD patients will pull hair to make their appearance symmetrical and this is not trichotillomania. Other things that are not trichotillomania involve those who pull hair because of body dysmorphic disorder or psychotic disorders with delusions about their hair. Certain substances and neurodevelopmental disorders can lead to hair pulling as well. The treatment for trichotillomania involves managing what is a chronic condition. Medications and psychotherapy together can be used to aid recovery. There are many tips and tricks for relaxation and distraction that abort the hair pulling behavior. These are employed to decrease hair pulling. The medications used are the same ones employed in the treatment of OCD, including fluoxetine, sertraline, fluvoxamine, paroxetine, clomipramine, lithium, and valproate. SSRIs are used first, followed by mood stabilizers if more treatment is needed.

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EXCORIATION DISORDER (698.4) Excoriation disorder goes by the medical name of dermatillomania and is a skin-picking disorder associated with the impulse to pick at the skin, even when it causes damage. It is similar to trichotillomania and sometimes coexists with it. While both are obsessive-compulsive disorders, they share similarities with substance abuse disorders. While there have been many psychological and medical theories behind excoriation disorder, it is now recognized as an organically-caused mental disorder of the obsessive-compulsive classification. The major symptom is the compulsion to squeeze, pick at, or scratch a part of the skin when experiencing anxiety or stress. There may be a perceived defect there but this is not a requirement. Most sufferers scratch their face but other areas seen are the extremities and scalp. Some will switch areas to allow formerly scratched areas to heal. Most patients pick with their fingers; however, needles and tweezers can be used. Patients with excoriation disorder will feel embarrassed, guilty, helpless, and ashamed of their urges; however, they cannot stop them. About 15 percent have been hospitalized in the past for psychiatric reasons and 11 percent have had prior suicide attempts. Like trichotillomania, the behavior is triggered by depression or anxiety, which decreases the heightened level of arousal. In addition, the mean age at onset of excoriation disorder is during adolescence when acne breaks out. Another peak age is 30-45 years of age but this is less commonly seen. Some argue that excoriation disorder isn’t a separate disorder but is just a facet of OCD or body dysmorphic disorder. Others say it is just a bad habit and not a disorder. The reason why it is listed as a separate OCD-related disorder is that there are no obsessions and no concern over a bodily abnormality. Patients also refer to skin-picking as pleasurable and they experience a release and a sense of pleasure, which is similar to an addiction disorder. There is now a specifier on the DSM-V to include individuals who have good to fair insight into their condition (and a better prognosis), poor insight (and a worse prognosis), or absent insight (the worst prognosis as they are convinced their behaviors are appropriate). There may or may

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not be anxiety with this disorder, which makes it not an anxiety disorder but an OCD-related disorder. The patient must have recurrent skin picking that leads to skin lesions and repeated attempts to stop the behavior. The estimated prevalence of the disorder is 1-5 percent of the general population with only about 1-2 percent truly meeting all the criteria for the disorder, including suffering distress or problems in several life areas. Many will have the disorder around adolescence or before with a marked preponderance of females with the disorder. Childhood traumatic experiences are linked to the disorder and it persists after the “era” of acne goes away. There is a great deal of comorbidity with excoriation disorder, particularly mood and anxiety disorders. OCD is a common comorbidity and about 40 percent will have some type of drug or alcohol use disorder. About half of people with body dysmorphic disorder have skin picking. It is also linked slightly to trichotillomania. Patients with developmental disabilities often have skin-picking disorder as well particularly Prader-Willi syndrome. The neurotransmitter dopamine is felt to be linked to skin-picking as drugs that enhance dopamine (like methamphetamine and cocaine) will increase skin picking behaviors, while drugs that block dopamine and naltrexone will decrease skin picking. Only about a third of patients seek treatment for the disorder with SSRI drugs being the first line of defense against the disease. Other drugs, like naltrexone (which blocks dopamine), tricyclic antidepressants, and atypical neuroleptic drugs have been tried successfully for skin-picking behaviors. Topiramate is used for those with Prader-Willi syndrome who pick their skin.

SUBSTANCE/MEDICATION-INDUCED OBSESSIVE-COMPULSIVE AND RELATED DISORDER This is the name for any OCD symptoms that are secondary to taking a drug. This is a relatively rare disorder that usually causes things like hair-pulling or skin-picking in predisposed individuals. If the person meets the criteria for OCD before taking the substance, it isn’t substance-induced OCD. There is a specifier that includes “with onset during intoxication”,

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meaning that the onset is immediately after taking the drug. It can also occur during drug withdrawal, which is an anxious time for many people. There are just a few drugs that are recognized as causing substance-induced OCD. These are methamphetamine, amphetamine, and cocaine. There is a category for “other” or “unknown” drugs but this would be quite rare.

OBSESSIVE-COMPULSIVE AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION This is a new category for the DSM-V. Most OCD conditions caused by a medical disorder involve things like excoriation disorder and trichotillomania. Organic disorders that can cause skin-picking behaviors include anemia, liver disease, kidney failure, allergic skin reactions, acne, and other skin disorders. Compulsive hair pulling can come secondary to a fungal infection of the scalp, scalp acne, psoriasis, seborrheic dermatitis, and other scalp conditions. Oddly enough, a streptococcal infection in kids can trigger a disease called PANDAS, which leads to the sudden onset of OCD and other neuropsychiatric symptoms. Wilson’s disease is an inherited disorder that results in liver disease and various psychiatric disorders, including OCD. Chelation therapy will help control the behaviors and other problems linked with this disease.

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KEY TAKEAWAYS •

Typical OCD is manifest as having obsessions (thoughts) and compulsions (behaviors) that must be performed in order to reduce the obsessions.

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SSRI drugs are a first-line drug for the management of all OCD-related disorders.

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Body dysmorphic disorder is an OCD-related disorder that is linked to unhappiness with a perceived body area.

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Trichotillomania and excoriation disorder are related OCD-related conditions that involve repetitive compulsions without any specific obsession.

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QUIZ 1. What type of emotional response is most common after experiencing an intrusive thought in obsessive-compulsive disorder? a. Guilt b. Anger c. Anxiety d. Disgust Answer: c. Most patients will exhibit an anxious response to an intrusive thought but there can be guilt or disgust if the thought was particularly ego-dystonic. 2.

What is the difference between delusional thinking and OCD thinking? a. Delusional thinking is more complex than OCD thinking b. The patient does not recognize the delusion as being made up, which isn’t the case in OCD. c. Delusional thinking has more bizarre themes than OCD thinking. d. OCD thinking is of a shorter duration than delusional thinking. Answer: b. The big difference between the two is that people with OCD recognize that their thinking is made up, which isn’t the case in delusional thinking.

Which drug therapy is a first-line choice in the treatment of obsessivecompulsive disorder? a. SSRIs b. Benzodiazepines c. Mood stabilizers d. Tricyclic antidepressants

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Answer: a. SSRI therapy is a first-line choice in treating patients who have obsessive-compulsive disorder. There are several SSRIs that work effectively along with behavioral and other forms of therapy. 4.

Which of the four specifiers of BDD has the worst prognosis? a. Dysmorphia b. Good or fair c. Poor d. Absent or delusional Answer: d. Patients with the absent or delusional BDD specifier have no insight as to their illness and cannot be swayed to believe any differently about their perceived physical defect.

What is not a common comorbidity to body dysmorphic disorder? a. Bulimia b. Major depressive disorder c. Substance abuse d. OCD Answer: a. Each of these is a typical comorbidity to BDD except for bulimia or other eating disorders as these patients do not change their eating habits to alter their perception of the indicated body area.

What is a good first-line treatment for body dysmorphic disorder? a. Tricyclic antidepressants b. Atypical antipsychotics c. SSRIs d. Benzodiazepines

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Answer: c. SSRIs, along with psychotherapy, seem to have effectiveness against the unusual perceptions seen in body dysmorphic disorder. 7.

In females, what is the average age at onset of trichotillomania? a. 5 years b. 13 years c. 21 years d. 35 years Answer: b. The disorder most commonly starts at or just after puberty, with a peak age at onset being 12-13 years of age.

Patients with trichotillomania will pull hair out of their bodies. From where do most patients take their hair in this disorder? a. Scalp b. Eyebrows c. Eyelashes d. Genital area Answer: a. Most patients will pull their hair out of their scalp, although any other body area with hair can be a location for hair pulling in trichotillomania.

What patient best describes trichotillomania? a. The patient who feels their hair is ugly and wants to pull it out b. The patient who is trying to get their hair symmetrical so they pull out their hair c. The patient who has delusions about wanting to be bald so they pull their hair d. The patient who has nervous tension that is relieved by pulling out their hair

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Answer: d. While hair pulling can be seen in any of these patient situations, it is called trichotillomania only if there is anxiety or tension that is relieved by pulling out their hair. 10.

Which illicit drug is least likely to be linked to substance-induced OCD? a. Amphetamine b. Methamphetamine c. Cocaine d. Opiates Answer: d. Each of these is associated with OCD and substance use except for opiates, which would rarely be linked to causing OCD-related symptoms.

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CHAPTER SEVEN: TRAUMA AND STRESSOR-RELATED DISORDERS This chapter focuses on the phenomenon of trauma and on trauma and stressor-related disorders. The most well-known example is post-traumatic stress disorder; however, there are many other trauma and stress-related disorders including reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders. There is also a category called other specified trauma and stressor-related disorder, which includes any disorder that has mixed features that don’t fit into any other specific category.

REACTIVE ATTACHMENT DISORDER (313.89) This is an attachment disorder that involves an abnormality of developmentally inappropriate moods, relationships, and social behaviors secondary to a failure to develop healthy attachments with the child’s primary care givers in early childhood. Children who experience separation, neglect, or abuse during the first three years of life run the risk of having an attachment disorder. There are two such disorders in the DSM-V: 1) Reactive attachment disorder (RAD) and 2) Disinhibited Social Engagement Disorder (DSED). Social relationships are inhibited at a young age in RAD so that the child does not engage in social interactions in a manner appropriate to their developmental age. They may fail to seek comfort when injured or upset, may avoid social reciprocity, and may become overly attached to one adult. While this is a childhood trauma disorder, it does affect behavior and relationships when the child grows up. The indication of the disorder occurs in early childhood with abnormal social interactions. The child might avoid starting or responding to social cues, even from family members.

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The child will have these symptoms, according to the DSM-V: A. Failure of normal physical and psychosocial development B. Lack of normal hygiene C. Poor motor coordination with hypertonic musculature D. Unfocused and under-stimulated appearance E. Blank expression and blank, unfocused eyes F. Failure to respond to interpersonal exchanges The symptoms must be present for 12 months to make the diagnosis and there is a specifier for severe disease. These children have had significant early abuse and neglect. They need extra attention and nurturing not always available from their parents. Parents need to be cautious about frequently changing caregivers when dealing with this situation as it will worsen the symptoms. The child will sometimes be socially unattached to siblings and peers, seeking only attachment to their neglectful parents. RAD can lead to avoidance of intimacy, anger, uncooperativeness, aggressive behavior, mistrust of adults, school difficulties, and social awkwardness. When it comes to treatment, parents must be involved in therapeutic intervention. This disorder can cause severe detachment from others later in life. The earlier treatment begins, the better the potential is for a positive treatment outcome. Attachment therapy helps with symptoms related to attachment problems in adopted children. Trauma-focused cognitive behavioral therapy seems to help some with the disorder. These are children that are motivated by harm avoidance and who have maladaptive emotional regulation in which they dissociate from potential threats in their environment.

DISINHIBITED SOCIAL ENGAGEMENT DISORDER (313.89) This disorder, referred to as DSED has the exact code as does reactive attachment disorder, reflecting their similar etiologies and treatment. This is a different disorder than RAD, however, as it represents a pattern of behavior in which the child prominently and actively tries to

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engage with strangers. This is a result of severe neglect in the first two years of life. It is commonly seen in children who have been institutionalized in infancy and who have not developed consistent attachments to any specific person. The main feature is the indiscriminate attachment without fear to strangers. They will easily leave with a stranger without having any fear. This happens because of a neglectful childhood, starting in infancy. In fact, a background of severe social neglect is a required criterion in this disorder. It cannot be diagnosed in children under nine months old (as they haven’t had a chance to develop close attachments to family members) but is usually diagnosed after severe neglect in a child under two years of age. Other signs and symptoms include having developmental delays and malnutrition. Having a preexisting developmental delay isn’t a part of the diagnosis but it is seen more commonly in these children because they are more likely to be mistreated or placed in an institution. Many children rescued from neglectful environments will recover physically but will still often have DSED. This means that not all DSED-affected children will have physical symptoms. The major risk factor is institutionalism in infancy and early childhood. It doesn’t happen in every institutionalized child so children who have good medical care, good nutrition, and adequate stimulation have a decreased chance of having the disorder, but may still get it. Noninstitutionalized children who get it have parents with severe adjustment problems. Risk factors can include substance use, depression, personality disorder, poverty, and teen parenting in the parents of these children. This is exclusively a disorder of childhood and isn’t diagnosed after five years of age. There are likely difficulties that extend to adulthood but it hasn’t been well studied. As the need for a caregiver decreases, the symptoms will decrease as well. Treatment involves developing a true deep attachment to the child and working through difficulties as the attachment the children develop tends to be very shallow and superficial. Play therapy and creative arts therapy can help the young child with this disorder. Children with the disorder need to use all five senses to learn to interact with and attach to a primary caregiver so these modalities are used in the

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treatment of DSED.

POSTTRAUMATIC STRESS DISORDER (309.81) There have been several changes to the criteria listed for post-traumatic stress disorder (PTSD). It is considered a trauma-related anxiety disorder that develops after psychological trauma secondary to an actual or threatened death experience, serious injury, or sexual violation. It can involve the person experiencing the threat, witnessing the traumatic event, or learning of the trauma. The trauma can be car accidents, war experiences, natural disasters, domestic violence, or sexual abuse. The symptoms must cause distress or occupational dysfunction for a minimum of one month. The symptoms cannot be related to a medical condition or substance use. The typical symptoms include flashbacks, nightmares, mood disorders, sleep disturbance, avoidance, suicidal ideation, and hyper-arousal when exposed to trauma-related stimuli. The hyper-arousal can include increased heart rate and blood pressure, hyperventilation, fatigue, insomnia, and mood swings. There can be an internal (cognitive) or external (environmental) stimulus. Patients will have insomnia, anhedonia, and attention deficit problems. Typical comorbid conditions include major depression, substance abuse disorders, and anxiety disorders. There are four categories or clusters of symptoms, used for individuals older than six years of age. These include the following: A. Alterations in arousal—aggressive, self-destructive, or reckless behavior, sleep disturbances, and hypervigilance B. Re-experiencing the event—traumatic nightmares, recurrent memories of the event, dissociation, and prolonged psychological distress C. Avoidance—thoughts, distressing memories, and reminders of the event

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D. Negative alterations in cognition and mood—distorted blame, persistent negative beliefs, trauma-related emotions, such as feelings of alienation and diminished interest in life There are two subtypes of PTSD, according to the DSM-V. These include the following: A. Preschool subtype—this is used in children under six years of age, where the diagnostic threshold is lowered. It is also lowered for older children and adolescents. B. Dissociative subtype—this is used when the patient has prominence of dissociative symptoms. These include depersonalization and derealization symptoms. All of the other criteria for PTSD need to be met. Common therapies for PTSD include cognitive behavioral therapy, exposure therapy, psychotherapy, and EMDR (eye movement desensitization and reprocessing therapy). Drug treatments include antidepressants such as SSRIs. The new age classifications given by the DSM-V indicate lower thresholds for making the diagnosis of PTSD in young children, school-age children, and adolescents. The most effective therapy has been cognitive behavioral therapy, although all other therapies can be effective. More complex treatment strategies need to be used when comorbidities exist. The traumatic event can lead to auditory hallucinations, inability to speak, and other unusual symptoms. CBT has been used with structured writing therapy for those who are also suffering from substance abuse. Integrated exposure therapy has also been used along with therapies that stress emotional regulation. Virtual reality exposure therapy has been used for phobias and for PTSD from war-time trauma. Over time, the exposure results in decreased anxiety and fear. Under the DSM-V, emotional reactions to the traumatic event, such as fear and helplessness have been excluded from the manual as criteria for the disorder. Even so, there has been increased recognition that PTSD can come from working in high risk professions, such as policing, the military, firefighting, and emergency medicine. There is significant impairment of daily functioning in people who have been exposed to long-standing trauma, such as child 115

abuse and wartime trauma. Depression as a comorbidity further worsens the quality of life. These patients will have more health problems, worsened social functioning, and higher rates of violence in their lives and suicide.

ACUTE STRESS DISORDER (308.3) Acute stress disorder is a specific trauma and fear disorder with symptoms lasting a minimum of three days and a maximum of one month after the traumatic event. The event can be a witnessed death, the threat of death, serious injury, or sexual assault. Things like natural disasters, muggings, sexual assault, physical assault, and serious accidents can trigger this disorder, as can repeated exposure to traumatic events. Patients do better with a decreased risk for the disorder when crisis intervention is employed. When this isn’t done or isn’t available, acceptance and commitment therapy can help. Individuals with acute distress disorder primarily have intrusive memories or thoughts of the traumatic event. Distressing dreams about the trauma and general sleep disturbances are not uncommon. Flashbacks and exposure to the stressor will trigger distress. The patient may block out memories of part or all of the event. Unrealistic feelings or beliefs about the event can occur as can depression, negative mood, anhedonia, concentration problems, and hypervigilance. Physical symptoms, such as sensory disturbances, headaches, and dizziness can be seen. This disorder can be seen in children who may have no real memory of the event but will have physical symptoms, disturbances in play, and nightmares. It can affect every area of the person’s life. In adults, it can lead to relationship problems, being late or absent from obligations, and significant sleep disruption. They will have problems feeling happy or joyful. Impulsive and reckless behaviors can manifest themselves. Substance abuse can be seen as a longer-lasting phenomenon. The prevalence of acute stress disorder after an interpersonal trauma is about 50 percent, while for other catastrophic events, the incidence is less than 20 percent. Half of all PTSD patients started with acute stress disorder.

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There is an emphasis on dissociative symptoms in acute stress disorder that are more prominent than is seen with PTSD. These symptoms include feeling detached from an experience, feeling numb, or being unable to remember traumatic events, even when treated shortly after the trauma occurred. Having these symptoms predict the onset of later having PTSD, with symptoms occurring more severely after the dissociative symptoms cease to occur. Treatment of acute stress disorder involves attempting to prevent the development of PTSD, which is more difficult to treat. Debriefing and crisis therapy are used immediately after the event to promote safe feelings in the trauma victim and to encourage victim connectedness and hope. Group therapy that involves a collective treatment of multiply traumatized patients helps in certain circumstances. Brief individual therapy can help the patient who was the lone victim of a traumatic event. Acceptance and commitment therapy is a type of psychotherapy that involves mindfulness and acceptance of the traumatic event. With this therapy they learn to live in the present moment and see hope for the future rather than continually living in the past at the time of the traumatic event. Stress reduction techniques are necessary for the prevention of the development of PTSD in the future. Patients can use a variety of techniques to decrease perceived stress during the period of time shortly after experiencing the trauma.

ADJUSTMENT DISORDERS An adjustment disorder involves sadness, feelings of being overwhelmed, and hopelessness that occur after a person has experienced a major life stressor. The symptoms are out of proportion to the precipitating event. These symptoms can disrupt normal mental health and functioning, leading to relationship problems, decreased work, school, and home performance, and worsening of existing mental and physical health conditions the patient may have. There are internalizing and externalizing symptoms of adjustment disorder. Internalizing symptoms are turned inward toward the patient and include things like decreased self-esteem, sadness, loneliness, hopelessness, loss of pleasure, shamefulness, and anxiety. Other

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internalizing symptoms can include feeling overwhelmed, self-harm, suicidal ideation, difficulty making decisions, concentration problems, poor appetite, and sleep disturbances. Externalizing symptoms include irritability, rage, crying spells, ignoring obligations, absenteeism, legal problems, tardiness, and suicidal behavior. Each patient’s symptoms are unique and create a cluster of subtypes of the disorder that vary according to the person’s cluster of symptoms. There can be adjustment disorder with anxiety, adjustment disorder with depressed mood, adjustment disorder with mixed mood and anxious features, and adjustment disorder with a disturbance of conduct. There is also unspecified adjustment disorder for mixed features. An identifiable stressor must have occurred in order to have an adjustment disorder. The symptoms occur shortly after the stressor. The symptoms affect the entire person—mind, emotions, body, and behaviors. The symptoms are indicative of poor coping strategies related to a stressful event. According the to the DSM-V, the adjustment disorder involves symptoms related to an identifiable stressor occurring within three months of the onset of the stressor. The distress must be out of proportion to the expected reactions, must cause distress and functional impairment, and must not be an escalation of existing mental disorders. It cannot be a part of the normal bereavement process. Symptoms must subside within six months after removal of the stressor. The symptoms will vary according to the patient and can mimic other disorders, including anxiety disorders, substance use disorders, depression, and personality disorders. The key in the diagnosis is that a stressor must occur and the adjustment symptoms happen first, before the onset of any other disorder. While the symptoms are maladaptive, they do not reach the criteria seen in PTSD or acute stress disorder, which are considered more severe.

OTHER SPECIFIED TRAUMA- AND STRESSOR-RELATED DISORDER (309.89) This is a catchall diagnostic category that includes symptoms that remain longer than six months without the stressor present in adjustment disorders, subthreshold PTSD symptoms,

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persistent complex bereavement disorder, and certain cultural trauma-related disorders that do not fully meet the criteria for any of the other trauma-associated mental illnesses.

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KEY TAKEAWAYS •

There are two attachment-related disorders caused by severe neglect and/or abuse before the age of 2-3. These can be seen in institutionalized children and other children abused at a young age.

•

Acute stress disorder is of a shorter duration than PTSD and involves a prominence of dissociative symptoms and intrusive thoughts about the traumatic event.

•

PTSD persists six months or more after a traumatic event and can last for years unless intervened upon with cognitive behavioral therapy or other trauma-based therapies.

•

Adjustment disorder involves an identifiable stressor and a response that is out of proportion to the stressor experienced by the patient.

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QUIZ 1. What is the difference between reactive attachment disorder and disinhibited social engagement disorder? a. RAD develops in early childhood and DSED develops later in life. b. RAD involves social withdrawal behaviors and DSED involves inappropriate attachment to strangers. c. RAD is an attachment disorder while DSED is a neurodevelopmental disorder. d. RAD is only seen in childhood but DSED can be seen in adults and children. Answer: b. Both are attachment disorders; however, RAD involves behaviors associated with social withdrawal and DSED involves having inappropriate attachment to strangers. 2.

At what age does the majority of abuse and neglect seen in reactive attachment disorder first begin? a. Less than 3 years of age b. Between 3 and 5 years of age c. School age children d. Adolescence Answer: a. The abuse and neglect seen in reactive attachment disorder first begins prior to three years of age. This is when a child’s first attachment normally develops.

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How long do the symptoms of reactive attachment disorder have to be present in order to make the diagnosis, according to the DSM-V? a. 4 weeks b. 3 months c. 6 months d. One year Answer: d. The symptoms of RAD must be present for a full year to make the diagnosis, according to the DSM-V criteria.

What is the maximum age at which disinhibited social engagement disorder can be diagnosed? a. Nine months b. Two years c. Five years d. Twelve years Answer: c. This is a disorder of very young children who are diagnosed with the disorder prior to the age of five years.

Which of the following is generally not associated with PTSD? a. Car accident b. Domestic violence c. Natural disaster d. All of these are associated with PTSD. Answer: d. According to the DSM-V, the diagnosis of PTSD can be made after many different types of trauma, including war, natural disasters, car accidents, sexual abuse, or domestic violence. The range of possible traumatic events has expanded in the DSM-V.

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How long do the symptoms of PTSD need to last at a minimum in order to make the diagnosis? a. 1 week b. 1 month c. 6 months d. 1 year Answer: b. PTSD symptoms must last for a minimum of one month in order to call it PTSD versus the much shorter acute stress reaction.

Which type of therapy has been found to be most successful for PTSD? a. Eye movement reprocessing therapy b. Exposure therapy c. Psychotherapy d. Cognitive behavioral therapy Answer: d. Cognitive behavioral therapy has been determined by many studies to be the most successful treatment for patients with PTSD, although the other types of therapy may be successful.

What is the minimum amount of time symptoms of acute stress disorder need to be present in order to have the diagnosis? a. One day b. Three days c. Two weeks d. One month Answer: b. The symptoms of acute stress disorder must last a minimum of 3 days and up to a month after experiencing the traumatic event.

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Which event is least likely to lead to acute stress disorder? a. Being mugged b. Sexual assault c. Hearing about a traumatic event d. Being injured in a car crash Answer: c. Any violent or near-death experience can trigger acute stress disorder; however, hearing about a traumatic event will usually not cause the symptoms to surface.

10.

How long after removal of the stressor can the symptoms of adjustment disorder last, according to the DSM-V? a. One month b. Three months c. Six months d. One year Answer: c. The symptoms must start within three months of the stressor and must go away within six months of removal of the stressor.

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CHAPTER EIGHT: DISSOCIATIVE DISORDERS Dissociative disorders are the topic of this chapter. These are unique disorders that sometimes have their basis in trauma but can be stress-induced. The DSM-V has listed four different dissociative disorders. The most well-known is dissociative identity disorder, formerly known as “multiple personality disorder.” Other dissociative disorders include dissociative amnesia, depersonalization/derealization disorder, and other specified dissociative disorder, which carries features of several of the other known dissociative disorders.

DISSOCIATIVE IDENTITY DISORDER (300.14) Dissociative identity disorder or DID was previously known as multiple personality disorder. In order to qualify for the disorder, there must be at least two distinct and separate personalities or alters within the same person with only one personality in control at any given period of time. The different personalities affect the individual’s behavior and conduct when they are “present.” The disorder cannot be from a drug or alcohol addiction and cannot be due to a medical/neurological disorder (such as epilepsy). This has been a controversial diagnosis that has been attributed to misdiagnosis, hysteria, or hypnotic suggestion. This means that only a small number of psychiatrists are well-trained to make the diagnosis or treat people who have DID. The symptoms are sometimes difficult to differentiate from other types of disorders—both mental and physical. It can be similar to seizure disorders, PTSD, and substance use disorders, which must be ruled out as possible causes. Typical symptoms include an inability to recall significant memories of childhood, lack of awareness or inability to explain certain activities, unexplained sleep disorders, eating and food issues, anxiety or panic attacks, mood swings,

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changes in handwriting, self-harm or suicidal ideation, out of body experiences, hearing voices or having out of body experiences, detachment or disconnection from body or thoughts, lost time (one of the major features), and flashbacks or sudden return of memories. Less commonly seen in DID are mood swings, depression, anxiety symptoms, eating issues, sleep problems, headaches or body pain, and sexual issues like sex addiction or sexual avoidance. The general prevalence of DID is about 0.4-3 percent, which is a wide variation but speaks to the fact that it is difficult to diagnose and the fact that there are a number of undiagnosed individuals with the disorder. The onset of dissociative symptoms generally begins between 5 and 10 years of age with alters formed by age six. The disorder is most frequently seen in females and isn’t diagnosed until the 20s or 30s. There will be more alters as the child ages with more than 20 alters seen in adolescents, although the number will go down with treatment. Childhood abuse is the most common etiology, particularly sexual abuse as a child. The patients will often dress differently from one another and will have both sexual promiscuity and difficulty attaining an orgasm. Hearing voices is common as is referring to oneself as “we” rather than “I.” The goal for the treatment of patients with DID is integrated functioning. The patient must be viewed as a “multiple” that has identities that share the responsibilities of life. Switches can occur at any time and the therapist needs to deal with the alters’ often competing points of view. The different parts need to learn to be aware of one another and resolve the conflicts between them. Eliminating or ignoring entities is counterproductive to the therapeutic goal as this simply does not work. An intermediate goal is to achieve integration, where the identities can harmoniously coexist. Finally, fusion is a tertiary goal, in which there is a loss of subjective separateness. Final fusion involves the presence of a single unified self. Unification is another term for “final fusion” and represents the end of the therapeutic goals involved in treating DID patients. Not all patients can achieve nor do they want to achieve unification. Cooperation among the alters is a reasonable goal for some patients who will have reasonable degrees of functioning.

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There are three phases to the individual psychotherapy used in the treatment of dissociative identity disorder. In phase one, there is the establishment of safety, reduction in symptoms, and stabilization. Phase two involves confronting and working through the traumatic memories. Phase three involves integration and rehabilitation. Besides the preferred treatment of individual psychotherapy, patients can participate in family systems therapy, cognitive therapy, clinical hypnosis, and creative arts therapy. It does not respond to medications unless there is coexisting anxiety and depression.

DISSOCIATIVE AMNESIA (300.12) Dissociative amnesia or DA is one of the three specified dissociative disorders seen in DSM-V. There is a transient loss of recall memory in this disorder that can occur over a few seconds or a few years. This is almost always secondary to psychological trauma. It involves memory loss that is beyond that seen with typical forgetfulness. The patient may forget key details of what happened before or during a traumatic event but will remember other details. This usually arises out of childhood traumatic events but can be difficult to actually diagnose. In older individuals, it can stem from war trauma or stressful situations that involve extremes of emotions that the individual cannot cope with. There are brain abnormalities in the right temporo-frontal cortical area in individuals who have dissociative amnesia. The main criteria of dissociative amnesia, according to the DSM-V, include the following: •

Inability to recall autobiographical memories about a traumatic event

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Distress caused by the inability to remember the event

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There is no physiological cause of the lack of memory

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The disorder is not secondary to dissociative identity disorder

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There is no substance use or abuse involved

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Having suppressed memories can be harmful to the patient and sometimes requires treatment. The partial memory recall can lead to flashbacks and nightmares. It is often a comorbid state with PTSD and can lead to self-destructive or self-harming behaviors or aggression against others. Dissociative fugue is not a separate disorder in the DSM-V but is a subtype of dissociative amnesia. In dissociative fugue, the patient often leaves their home and assumes a new identity far from where they used to live. Daily life can trigger the person to dissociate more. The condition of DA can affect a person’s work-life, where they may fail to remember key aspects of their job. Relationships can suffer and families can be stressed by the depressed and confused state of the family member who has lost their memories. Friends and family can play an important role in helping the individual recover lost memories. Cues and storytelling with the help of a therapies can help recover memories without furthering dissociation. Relaxation can help as well. Some will improve with mindfulness therapy. The object of any treatment for dissociative amnesia is to reintegrate the memories and relieve the patient of fragmentation. The disorder is difficult to treat and most commonly spontaneously resolves however, it can take many years for this to occur. Treatment can, on the other hand, reduce the underlying symptoms, helping the patient decrease depressive and suicidal symptoms. The comorbidity of PTSD can be treated with therapy. The major treatment involves psychotherapy, which includes dream analysis and memory training in order to retrieve hidden memories. Cognitive-based therapies are the most effective at reducing the symptoms and improving memory recall. Dissociative fugue is fascinating to many people and is a subtype of dissociative amnesia in the DSM-V. These are people who change their identity and move to a new location after a traumatic event or accident. Once they are discovered and identified, they undergo a slow or spontaneous recovery, in which they gradually recover their lost memories and resume their regular daily activities.

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DEPERSONALIZATION/DEREALIZATION DISORDER (300.6) These are actually two disorders that have been redefined as a single entity in the DSM-V as they have similar symptoms and a similar etiology. These people have ongoing or recurrent feelings of bodily or cognitive detachment from their environment or themselves. They maintain a connection to reality, which differentiates these patients from other dissociative disorders. The patient is distressed by this detachment and often feels robotic. Depersonalization involves viewing themselves from the outside or being “outside of themselves,” while derealization involves detachment from the environment and other people. The patient feels like they are in a dream. The prevalence of the disorder is seen in about 2 percent of the general population. It affects men and women the same and is felt to be an underdiagnosed illness. The onset of the disorder is at about 16 years of age (the mean age of onset). The major symptoms of depersonalization include the following: •

Emotional detachment

•

Distortion of body image

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Difficulty recognizing one’s own image in a mirror

•

Anesthesia of a body part or parts

•

Feeling like a spectator outside of the body

The major symptoms of derealization include the following: •

Feeling detached from one’s surroundings

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Feeling that life events are unreal

•

Seeing objects as changing in shape, color, or size

•

Feeling like known people are strangers

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•

Feeling of being in an unfamiliar environment when this isn’t the case

The patient may also feel like both of these symptom clusters are happening at the same time. The symptoms may be sporadic in nature or chronic. As a whole, these types of dissociative disorders are difficult to diagnose. This can be because there is a great deal of comorbidity with them, there is often a lack of information on early childhood trauma, and the patient may have difficulty recalling past unpleasant events in their lives. The DSM-V criteria include the following: 1. The presence of depersonalization and/or derealization 2. There are no other disorders or substances to account for the symptoms 3. The individual knows their experiences are not real and have intact reality 4. There is significant distress or social/occupational impairment There are no single causes for depersonalization/derealization disorder; however, there are often episodes of severe distress, depression, and panic attacks, and the misuse of drugs like hallucinogens and marijuana. The disorder often stems from childhood trauma especially emotional abuse or neglect. It can involve a history of seeing a severe accident or being assaulted or emotionally abused as an older person. Typical comorbidities linked to depersonalization/derealization disorder include PTSD, anxiety disorders, depression, avoidant personality disorder, borderline personality disorder, or obsessive-compulsive disorder. Things that must be ruled out as possible differential diagnoses include bipolar disorder, schizophrenia, PTSD, drug or alcohol abuse, medication use or medication withdrawal. People with this disorder are distressed by it and can have social or occupational impairment. The individual may have an inability to function normally in everyday tasks and in social situations. The dissociation can lead to anxiety, which feeds back and increases the symptoms.

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There is no cure for the disorder but there can be treatment with psychotherapy and medications, which can be used together or separately. Psychotherapy can include counselling, cognitive behavioral therapy, grounding techniques, and psychodynamic therapy. There are a number of drugs that can be used, including tricyclic antidepressants, clomipramine, fluoxetine (an SSRI), lamotrigine (an anticonvulsant), and opioid antagonists that block the body’s response to endorphins and opioids. The prognosis is generally good with treatment.

OTHER SPECIFIED DISSOCIATIVE DISORDER (300.15) Patients with this disorder have varying dissociative symptoms that don’t fit the diagnosis of any particular dissociative disorder. There is a loss of awareness of one’s surroundings or a lack of complete orientation to their surroundings. The patient may have a “dissociative trance,” in which they are unresponsive to outside stimuli. They may feel paralyzed as though things around them are blurry or surreal. There is a detachment of awareness of who the person is. This is especially seen in patients who’ve endured long periods of abuse, captivity, or torture. Other individuals with other specified dissociative disorder have an acute dissociative reaction to a severe stressor or trauma called the “syndrome of mixed dissociative symptoms.” These patients will experience amnesia of part of the event, a sensation of time slowing down, “tunnel vision,” and the feeling of being on an analgesic or anesthetic. There is a diagnosis of unspecified dissociative disorder, in which the patient has a dissociative event or condition that does not fit into the typical presentation of a known dissociative condition. The source may be unclear and things like a head injury after a head trauma or car accident can cause dissociation that may or may not be medical in origin. This is the diagnosis given when there is dissociation but no clearly defined dissociative disorder.

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KEY TAKEAWAYS •

Dissociative identity disorder is at the extreme end of dissociative disorders and represents the splitting of the person into two or more distinct personalities after psychological trauma.

•

Dissociative amnesia involves having forgotten key details of a traumatic event that leads to distress and impairment in day-to-day activities.

•

Depersonalization/derealization can be a chronic or episodic dissociative state in which the person feels detached from themselves or their surroundings.

•

Dissociative fugue involves trauma and changing one’s identity thereafter, which is a subtype of dissociative amnesia.

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QUIZ 1. The dissociative disorder that presents as two or more alters inhabiting the same body is called what? a. Dissociative fugue b. Dissociative identity disorder c. Dissociative amnesia d. Depersonalization disorder Answer: b. Patients with dissociative identity disorder have at least two independent alters that inhabit the same body and manifest at different times. 2.

What is the least likely disorder that will need to be ruled out in order to make the diagnosis of dissociative identity disorder or DID? a. Seizure disorder b. Substance use disorder c. PTSD d. Reactive attachment disorder Answer: d. Each of these disorders can represent something that could have similar symptoms to DID; however, reactive attachment disorder is a disorder of mainly children that has different symptomatology but may have a similar etiology.

What is considered a major feature of dissociative identity disorder? a. Lost time or memory lapses b. Anxiety or phobias c. Mood swings d. Sleep disturbances

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Answer: a. The finding of lost time or memory lapses is a major feature of DID. The others are seen but not as commonly so. 4.

What is considered the final goal in treating patients with dissociative identity disorder? a. Individualization b. Unification c. Fusion d. Integration Answer: b. With unification, the individual finally sees themselves as a single person rather than a collection of different personalities.

What is the treatment of choice among patients with dissociative identity disorder? a. SSRIs b. Creative arts therapy c. Individual psychotherapy d. Clinical hypnosis Answer: c. The main treatment of choice is individual psychotherapy, although other treatment modalities listed can also be used, depending on the therapist and the situation.

Which dissociative disorder is not recognized by the DSM-V as a distinct disorder of this classification? a. Dissociative fugue b. Dissociative amnesia c. Dissociative identity disorder d. Derealization/depersonalization disorder

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Answer: a. Dissociative fugue is not a distinct disorder as identified by the DSMV. 7.

What is the major feature of depersonalization? a. Detachment from oneself b. Feeling as if in a dream c. Panic attacks d. Disorganized thinking Answer: a. The patient has detachment from themselves and feels like they are seeing themselves from outside their body or are disconnected from their body.

What is the mean age at onset of depersonalization/derealization disorder? a. 8 years b. 16 years c. 21 years d. 30 years Answer: b. The mean age at onset of this disorder is about 16 years of age.

Which is considered a diagnosis of derealization versus depersonalization? a. Feeling like body parts are distorted b. Inability to recognize self in the mirror c. Anesthesia of a body part d. Feeling like known people are strangers Answer: d. Each of these is a characteristic of depersonalization, except for feeling like known people are strangers, which is a feature of derealization.

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10.

What best describes the situation where there is dissociation that doesn’t meet the criteria of any obvious dissociative disorder? a. Dissociative trance b. Mixed dissociative disorder c. Dissociative fugue state d. Unspecified dissociative disorder Answer: d. The diagnosis of unspecified dissociative disorder is given as a “working diagnosis” when there is dissociation that doesn’t meet the criteria of any specific dissociative disorder.

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CHAPTER NINE: SOMATIC SYMPTOMS AND RELATED DISORDERS The topic of this chapter is the different somatic disorders, beginning with somatic symptom disorder. There are several different somatic disorders with psychological origins or features that are recognized by the DSM-V as distinct entities. These include things like illness anxiety disorder, conversion disorder, and factitious disorder. There is a category for “psychological factors affecting other medical conditions,” which involves the different psychological states that influence the outcome of physical disorders.

SOMATIC SYMPTOM DISORDER (300.82) Somatic symptom disorder or SSD involves recurrent and frequent bouts of physical complaints that have their onset prior to 30 years of age. According to the DSM-V, the requirement that they be medically unexplainable is not necessary. Typical complaints seen by those with SSD include dizziness, chest pain, headaches, limb pain, and abdominal pain. The category of somatic symptom disorders has replaced “somatoform disorders” with the recognition that somatic symptoms can be present in a wide variety of illnesses. There is now a rating scale with regard to somatic symptoms. In SSD, the symptoms are produced unconsciously, which is not the case in malingering and factitious disorder. As mentioned, there does not have to be a mind-body dualism so that SSD can be diagnosed when there is a coexisting medical disorder. Instead of dualism, the patient’s thoughts, behavior, and feelings about their symptoms are out of proportion or excessive in relationship to the medical diagnosis. According to the DSM-V, the symptoms must be present for a minimum of six months, with symptoms that take up extra time and energy on the part of the patient. 137

The symptoms must have some clinical significance, requiring medical attention and impairing function. They must be wholly unconscious and not intentionally produced. They may be medically explainable but the patient’s reaction to them must be out of proportion to the actual physical disease. The patient’s thoughts and feelings about their disorder must have a significant impact on their ability to be successful in their daily functioning. Creating physical complains subconsciously play a role in avoiding certain situations and withdrawing from uncomfortable events. This is the way the patient copes with things they do not tolerate. Social support tends to be lacking for these individuals and they may be using their symptoms to get attention. Risk factors for somatic symptom disorder include genetics, family history, and early traumatic experiences, with the learning that illness is culturally acceptable and attracts attention. Stressful life events, such as childhood physical illnesses, family dissolutions, physical abuse, and sexual abuse can cause this problem to surface. This tends to develop in childhood and will persist until adulthood. The patient usually seeks medical attention first because they believe they have a physical illness. They may spend a great deal of time with mainstream medical doctors before receiving a psychiatric diagnosis that better fits with their true diagnosis. The new DSM-V category allows for the diagnosis to be made even before all physical causes have been ruled out. Treatment can include psychoeducation, behavioral therapy, and psychotherapy. Hypnosis can be used to help develop better coping skills. Cognitive behavioral therapy has also been found to be effective. Children with SSD can become involved with family therapy once the correct diagnosis is made. This can help with family issues that might be contributing to the disorder and can begin to treat the patient early in the course of the disease. Parents also need help in decreasing their anxiety and stress over having a child with recurrent physical symptoms. Untreated children with SSD will often have symptoms that persist into adulthood.

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ILLNESS ANXIETY DISORDER (300.7) Illness anxiety disorder or IAD used to be called somatoform disorder or hypochondriasis. It involves excessive concern over one’s health in the absence of objective or verifiable evidence of a health condition. These patients will have excessive body vigilance and health-related anxiety. Historically, it was related to depression and melancholy, although this does not have to be the case. The main symptoms include the following: •

The belief that one has a serious illness or will get one.

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There will be no symptoms or there will be only mild symptoms (such as tachycardia or dyspnea)

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The patient’s concern over their health is out of proportion to reality.

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There is hypervigilance about one’s health and subjective distress over health changes.

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Frequent checking of vital signs or other evidence of sickness.

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Avoidance of medical care because they fear that something bad will be found.

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Persistence of symptoms for longer than six months.

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Another illness or psychiatric disorder cannot explain the symptoms.

Other diseases that can mimic this is somatic symptom disorder, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, or a psychotic episode with somatic delusions. The two main specifiers include the “care-seeking type” that tends to frequently seek medical care and the “care-avoidant type” that avoids medical care out of anxiety of having a serious diagnosis. Other aspects of the clinical presentation include making dramatic statements about one’s health, having self-pity, exaggerating the impact of symptoms, preoccupation with minor

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injuries, claiming to have unverifiable disorders, and lack of response to reassurance that they are well by healthcare providers. Often, a thorough medical workup with consultation with specialists will fail to lead to any objective evidence of a serious problem. The patient will frequently misinterpret physical symptoms and, if there is a real illness, it tends to be minor or self-limiting. These patients often react strongly to news of medical conditions of others or to the threat of disease. They may overreact to sicknesses in their children. They may adopt an imagined disease as the main source of their identity. They often thrive on medical attention and sympathy. They complain about their health excessively so that others avoid them. If they do develop a real illness, people often do not respond to the symptoms adequately, which can be a major health risk. They often fail to recognize their symptoms as being related to a psychological disorder. Patients may research the disease they imagine they have, often believing they have a rare medical disorder based on an incomplete knowledge of the disorder. They respond easily but temporarily to the placebo effect and will often develop other symptoms. They have many invasive diagnostic procedures and sometimes will undergo unnecessary elective surgeries. They tend to crave the care and attention they receive. They often have multiple care providers and will often frustrate their care providers, who aren’t as thorough as they want them to be. Iatrogenic disease can result from complications secondary to invasive diagnostics. Risk factors include having a first-degree relative with IAD through observation and learning of others’ behaviors. A personal or family history of an experience with the medical profession that diminished the person’s faith or confidence in healthcare can lead to IAD. Less common risk factors include having a serious stressor, child abuse, or serious illness in childhood. Things that must be ruled out with IAD, according to the DSM-V, include having real legitimate medical conditions, adjustment disorders, non-pathological health-related anxiety, somatic symptom disorder (who have more actual symptoms than IAD patients), anxiety disorders (such as GAD), major depressive disorder, and body dysmorphic disorder with a primary focus on an

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imagined flaw in their appearance. The differential diagnosis must also include Munchausen’s syndrome, malingering, and drug-seeking behavior. About two-thirds of individuals with IAD will have some psychiatric comorbidity. These include somatic symptom disorder, OCD (which may be primary and present with health-related impulses), generalized anxiety disorder, PTSD, psychosis, histrionic personality disorder, orthorexia (avoiding certain foods for no objective reason), or borderline personality disorder. Serious medical illnesses often get worse because the individual has been ignored in the past by healthcare providers. The patient with IAD will be reluctant to accept that they have a psychological illness and will often continue to believe they have a serious physical illness. Those that are amenable to treatment will improve with mindfulness cognitive behavioral therapy or rational emotive behavioral therapy. They can learn how to respond to benign or vague symptoms from the body. SSRIs can help manage this disorder because it has biological similarities to OCD, which also responds to this classification of drugs. The disorder can be difficult to treat but will respond to treatment if given appropriately.

CONVERSION DISORDER (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER) (300.11) This is a somatic disorder that is characterized by a motor or sensory dysfunction, representing a neurological condition that cannot be explained neurologically. It can be acute, coming and going suddenly or can persist for months. It is 2-3 times more common in women compared to men and often follows a stressful life event or period of stress. The symptoms involve unusual impairments in motor or sensory function that are not consciously developed. It can occur in children and adults. Typical symptoms include focal or generalized weakness, numbness (focal or generalized), tremors, seizures, difficulty walking, and involuntary movements. Speech and swallowing difficulties can happen as well as problems with the special senses (vision or hearing). Severe cases can involve the patient in an

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unexplainable coma. Dissociative symptoms can happen in the beginning but these aren’t the part of the DSM-V diagnosis. The patient may act as if they aren’t concerned about the symptoms, even when they are debilitating. Stress usually precipitates the attack but not necessarily. Mental health issues such as anxiety, depression, and childhood sexual abuse/PTSD are common. Typical comorbidities include eating disorders, anxiety disorders, panic disorder, personality disorders, and depression. The patient may also have other somatic disorders. Not usually seen as comorbidities are substance use disorders and psychosis. Different cultures throughout the world will have different main manifestations of this disorder. The reasons for the cultural differences in conversion symptoms are not known. In all cultures, however, it does follow a stressful experience. Treatment of conversion disorder involve several different providers, including psychologists, psychiatrists, and rehabilitation specialists. Comorbidities have to be treated. The patient may resist a psychiatric diagnosis at first but must eventually accept it if they are to improve. Psychodynamic and cognitive behavioral therapy can help overcome the symptoms with psychoanalysis helpful in about 70 percent of cases. Hypnosis is controversial but can also help resolve the symptoms. Post-hypnotic suggestions can be given with an 80 percent success rate.

PSYCHOLOGICAL FACTORS AFFECTING OTHER MEDICAL CONDITIONS (316) This is the diagnosis when the patient has a preexisting medical condition and has behavioral and/or psychological factors that negatively impact the outcome of the disorder. The patient generally has an identifiable medical illness and will do things that overtly or covertly make it worse. The patient may make it worse or may stop their recovery efforts, affect adversely the treatment of the condition, exhibit unhealthy behaviors, or may not do what the doctor tells them to do. The problem is not explained by another mental disorder. The disease can be mild, moderate, severe, or extreme, depending on the risk to the patient. Mild disease will increase the medical risk by noncompliance. Moderate disease will adversely 142

affect the actual underlying condition. Severe disease often worsens the condition to critical proportions so that the patient requires hospitalization. Extreme disease results in severe, lifethreatening risk to the patient. No one knows exactly how common this disorder is. In order to make the diagnosis, the individual must have at least one medical condition that is being adversely affected by the behavior of the patient. It can occur in both children, adults, and the elderly. A behavioral response that does not directly affect the medical outcome is considered an adjustment disorder. Psychotherapy and direct patient education can help improve the outcome.

FACTITIOUS DISORDER (300.19) The person with factitious disorder consciously and intentionally produces, fakes, or exaggerates the symptoms of a disease or psychological condition in order to assume the patient role. The patient may have different motives—from gaining access to drugs, having a personality disorder, being fascinated by the medical field, or having unresolved trauma from childhood (early detachment, physical abuse, or emotional abuse). These are different motives from malingering, which involves getting medical leave or wanting financial compensation. Munchausen syndrome is a serious type of factitious disorder in which the patient frequents doctors and hospitals, creating illness and fabricating evidence of a disorder. They may take injections to mimic other disorders or otherwise use their medical knowledge to fake medical illnesses. Most of these patients have a history in the medical field and have some type of personality disorder. They may fake a new illness when one is under control. Factitious disorder by proxy involves being a caregiver who induces symptoms of an illness in another person to gain sympathy. This patient is conscious of the intent to create false symptoms, which makes it different from other somatic symptom disorders. There are three types of factitious disorders: 1) Those with predominantly psychological signs and symptoms; 2) Those with predominantly physical signs and symptoms; and 3) those with combined symptoms. Just about any medical or

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psychological condition can be faked by individuals with this disorder. Factitious disorder can have differing impacts on daily functioning, depending on how severe it is. It places a major strain on the healthcare system with an overall high rate of medical utilization. This is a chronic condition that lasts the patient’s lifetime. It can pose serious threats to the patient’s or their children’s lives (or an elder’s life). It is considered a type of child abuse or elder abuse. The treatment is difficult as one must determine which aspect of the person’s presentation has been faked or purposely created. As in all somatic symptom-related disorders, more emphasis is made on the underlying psychological problems rather than on the behavior if the person is to be treated at all. Individualized behavioral therapy can address the underlying issues rather than being so confrontational. Pathological lying can make the diagnosis and treatment difficult. SSRIs can be used for anxiety and depression but these do not help treat the psychological pathology. Behavioral and cognitive behavioral therapy can treat mild-to-moderate cases.

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KEY TAKEAWAYS •

Somatic symptom disorder involves having symptoms that may or may not be medically explainable but are out of proportion to the medical illness, if there is one.

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Illness anxiety disorder involves excessive concern about one’s health and the belief that there is a serious physical illness that hasn’t been discovered.

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Conversion disorder mainly involves some type of unexplainable neurological symptomatology that follows a significant stressor.

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Factitious disorder is the intentional faking of medical symptoms for various reasons, most commonly to assume the “sick role.”

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Quiz 1. What change has been made in the DSM-V regarding somatic symptom disorder? a. It can now include non-pain-related symptoms b. It is now referred to as somatoform disorder c. The symptoms don’t have to be medically unexplainable d. It can occur in people of all ages rather than under the age of 30 years Answer: c. The symptoms now do not have to be medically unexplainable in the DSM-V when, in previous volumes, this was a requirement. 2.

Which condition is not listed in the DSM-V under somatic symptoms and related disorders? a. Malingering b. Factitious disorder c. Conversion disorder d. Illness anxiety disorder Answer: a. Malingering is the only one listed that is not considered a somatic disorder under the DSM-V.

How long must the symptoms of somatic symptom disorder be present in order to qualify as being SSD under the DSM-V? a. One month b. Six months c. One year d. Two years

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Answer: b. The symptoms must be present for a majority of time for a minimum of six months in order to qualify as being somatic symptom disorder under the DSM-V. 4.

Which psychiatric disorder would least need to be ruled out in patients suspected of having illness anxiety disorder? a. Somatic symptom disorder b. Dissociative amnesia c. Generalized anxiety disorder d. Obsessive-compulsive disorder Answer: b. Each of these disorders can mimic illness anxiety disorder and will need to be ruled out. This is not the case with dissociative amnesia.

What is considered a major risk factor to the development of illness anxiety disorder? a. Childhood neglect b. Childhood sexual abuse c. Childhood serious illness d. First-degree relative with IAD Answer: d. Having a first-degree relative with IAD is a risk factor because the patient will learn reactions to illnesses and symptoms that are excessive and based on anxiety.

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The patient will illness anxiety disorder can have several comorbidities. Which is least likely to be a comorbidity? a. Social anxiety disorder b. PTSD c. Histrionic personality disorder d. Obsessive-compulsive disorder Answer: a. There are many comorbidities that can be linked to illness anxiety disorder. Social anxiety disorder would least likely be expected as a comorbidity.

What comorbidity is least likely to be seen in patients who have conversion disorder? a. Anxiety disorder b. Psychosis c. Depression d. Eating disorders Answer: b. Psychosis tends not to be seen as a comorbidity along with conversion disorder; however, the others can be seen with this.

Which is the least likely treatment strategy to work in the treatment of conversion disorder? a. Hypnosis b. Psychodynamic therapy c. Cognitive behavioral therapy d. Family systems therapy Answer: d. Each of these is seen as helpful in the treatment of conversion disorder except for family systems therapy. Hypnosis and psychodynamic therapy have 70-80 percent success rates.

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What behavior least represents a psychological factor affecting a medical illness? a. Stopping a necessary medication b. Forgetting to make a doctor’s appointment c. Smoking in the face of severe lung disease d. Ignoring the symptoms of a stroke Answer: b. Each of these is a psychological factor that can affect a medical illness; however, simply forgetting to make a doctor’s appointment is least likely to represent this type of phenomenon.

10.

Which is not a phenomenon of factitious disorder? a. Background in the medical field b. Having unusual symptoms that can be serious c. Having a personality disorder d. Subconsciously desiring to be attended to by doctors Answer: d. The patient is completely conscious of their desires and of their motivations, unlike other somatic disorders, which are largely subconscious.

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CHAPTER TEN: FEEDING AND EATING DISORDERS The major topic of this chapter is feeding and eating disorders. The DSM-V sought this new category and included disorders like rumination disorder and pica to have an improved method of evaluating and treating eating-related disorders. The typical eating disorders, anorexia nervosa, bulimia, and binge-eating disorders remain as part of this classification. A newer subclassification of other specified feeding and eating disorders has been added to identify individuals that do not fit neatly in any other category.

PICA (307.52) This involves the persistent and compulsive urge to eat non-nutritive substances that aren’t considered to be food. It is usually diagnosed above the age of five as eating such substances by younger children is considered probably developmentally appropriate. Pica in adults usually happens in those who are intellectually disabled. Pica used to be under the heading of “disorders with onset in childhood and adolescence” but now is under the feeding and eating disorder category. This helps reduce the number of individuals in the eating disorder NOS category, which doesn’t exist in the DSM-V. There is now no upper age limit for pica. Items eaten include dirt, chalk, paper, feces, glass, and other non-food items. Pica may be linked to OCD, because they persistently diet on nonnutritive substances. They are completely conscious of their behavior and know it is both unhealthy and illogical. People who engage in pica may experience some of the same symptoms as a malnourished individual. They may have mineral deficiency, weight loss, and unhealthy hair and nails. They can get intestinal obstruction, abdominal pain, and other serious health problems. It is often

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coexisting with other mental disorders, such as schizophrenia, autism spectrum disorder, anorexia nervosa, and self-harm. People with factitious disorder can eat non-nutritive substances in order to mimic the symptoms of a more serious medical condition. The DSM-V criteria include persistently eating non-nutritive substances for a minimum of one month, eating these substances beyond what is developmentally appropriate, eating outside of culturally-supported norms, and eating that is severe enough, even in the face of another medical disorder, to warrant its own clinical diagnosis. It isn’t a specifier for OCD in the DSM-V, although this was suggested on the basis of cases that have shown OCD with pica as the sole manifestation. The onset of pica is usually in childhood, although it can be diagnosed at any age. It is seen more commonly in areas with low socioeconomic status and in developing countries. It has been linked to mineral and other nutritional deficiencies. Most of the research has been done in the developmentally disabled population, although neglect and lack of supervision in childhood are also risk factors for the disease. Child abuse in those kids who do not receive adequate nutrition. Some type of brain disorder may be present in some patients with pica. There is a link between iron or zinc deficiency and pica. On the other hand, if pica is a part of a medicinal, spiritual, and social value within the context of a cultural practice, it does not qualify as being pica under the DSM-V criteria. It represents a way to relieve anxiety in some people, making it a feature of anxiety disorders at times. Because it can lead to serious health problems, people can die from having significant pica. The goal of adding this and two other disorders under “feeding and eating disorders” in the DSM-V is to improve the treatment of these disorders. While little research on treatment of pica has been done, cognitive behavioral therapy (CBT) seems to be helpful as well as family therapy. Applied behavior therapy or ABT is one of the most effective therapies as it can be applied to people with comorbidities. It rewards positive behavior and punishes undesired behavior.

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RUMINATION DISORDER (307.53) This is an uncommon disorder that involves rumination or “regurgitation.” It involves the regurgitation of undigested foods that is not intended as a tool to lose or change weight. It involves people using abdominal contractions, tongue movements, or coughing to bring food back into the mouth. It can affect infants, children, and adults who have mental or intellectual disabilities. The disorder must last at least one month to make the diagnosis under the DSM-V guidelines. The adult with the disorder usually spits out the food but children and infants will chew and reswallow the regurgitated substances. It happens after nearly every meal and about 1-2 hours after the meal. The regurgitation must be unrelated to a GI disorder or to an eating disorder in which weight loss is the goal. In infants, it starts between the ages of 3 and 12 months. A key feature of rumination disorder is that individuals find the behavior pleasant. Still, many people who find it soothing or anxiety-relieving will be embarrassed by the behavior and will not report it. For this reason, the prevalence of the diagnosis is unclear. It appears to be at an increased risk in patients who are institutionalized. In infants with the disorder, it is often due to some type of medical disorder rather than a psychiatric one. There are other psychiatric disorders comorbid with other mental disorders, such as generalized anxiety disorder or intellectual development disorder. It can lead to malnutrition, esophageal damage, dental caries, bad breath, and dehydration. In infants, there can be failure to thrive and malnutrition. In older children, there can be learning and growth delays. It can be fatal in infants. It can affect social functioning in teens and adults, who are embarrassed by the behavior. There are no medical interventions or drugs that have been found to treat rumination disorder. It is a learned behavior, making behavioral therapy a good approach. One behavioral technique is called diaphragmatic breathing training. They learn how to relax and breathe differently during and after breathing, which controls the behavior to some degree because this type of

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breathing is physically incompatible with regurgitation. Chewing gum after breathing is also effective in stopping regurgitation, particularly in children and the developmentally delayed individual.

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (307.59) This is a new disorder in the DSM-V called ARFID. It can occur at any age but traditionally has been seen mainly as a childhood diagnosis. It is similar to anorexia but the patient restricts food but not because of a distorted body image. The person with ARFID restricts certain kinds of food so they don’t get as many calories as they should. The type of eating done in ARFID is worse than being a picky eater or avoiding foods because of an allergy or intolerance. The patient may have false beliefs about nutrition or may be selfdiagnosing themselves as having an intolerance to gluten, for example. There may be an aversion to the texture, taste, and smell of certain foods, or a problem with dysphagia or choking on certain foods. Common symptoms of ARFID include an indifference to food or eating, refusal to eat certain foods because of the characteristics of the food, rigidity about food, or concern about the effects of eating. The patient may fail to meet normal nutritional or caloric needs, resulting in weight loss or failure to thrive (in children). There can be nutrient deficiencies necessitating nutritional supplementation. These behaviors will cause stress around eating and the patients will avoid social activities involving food. It is not attributable to a lack of food or because of a social or religiouslyaffiliated practice. There is no perception of distorted body image as is seen in anorexia nervosa. There is a specifier for being “in remission.” The disorder will begin by the age of 10 years but will often persist through adulthood. ARFID is not a predictor of anorexia or bulimia; it is slightly different from food neophobia, which is the mistaken perception of food intolerance or allergy. It is seen more often in children than in adults and may persist for some time before it is diagnosed. Triggers for the 154

onset of the disorder include emotional problems, social difficulties, or certain physical illnesses. The prevalence is about 25-35 percent in normal children and higher in children with developmental delays or disturbances. Risk factors that precipitate ARFID include autism spectrum disorder, anxiety disorders, obsessive-compulsive disorder, and ADHD. Environmental risk factors include familial anxiety and having a mother with an eating disorder. Various GI disorders, such as reflux and vomiting, may precipitate ARFID. Choking on food can be a risk factor for ARFID. Comorbidities include anxiety disorders, OCD, autism spectrum disorder, ADHD, and intellectual disabilities. This disorder may be treated with psychoeducation and cognitive behavioral therapy that challenges the patient’s beliefs about fears of choking, food aversions, and other cognitive distortions related to food and eating. There is family tension associated with ARFID and, when it occurs in children, it can affect the parent-child interactions. Certain infants will display fussiness in their temperament that persists through childhood and adulthood.

ANOREXIA NERVOSA (307.1) Anorexia nervosa has been included in previous Diagnostic and Statistical manuals. The person has a preoccupation with having a low body weight and who exhibits many behaviors that contribute to having a low body weight. The person will restrict food intake and will even starve themselves of all food in order to avoid gaining weight. They may impulsively exercise on a frequent basis. A simple explanation is that they fear gaining weight but there are complexities to this simple explanation. There can be specific events or social pressures to be thin that predispose the individual to anorexia nervosa. The male to female ratio is 10:1 with an incidence of 0.4 percent per year. Although these patients go to great lengths to hide evidence of their condition, the typical symptoms that can be identified include the following: A. Obsession with the caloric and nutritional content of food B. Using appetite suppressants or laxatives to control weight 155

C. Having a distortion of body image D. Denying being of a low weight E. Being extremely thin or emaciated F. Eating very little or skipping meals G. Weighing oneself obsessively or constantly checking body shape in the mirror H. Vomiting after meals I. Having dizziness, physical problems, and dry skin Symptoms that develop over time include hair loss or brittle hair, growth of lanugo hair over the body, osteoporosis, muscle wasting/weakness, anemia and low blood pressure, constipation, infertility, fatigue, lethargy, brain damage, and organ failure. To meet the disorder, there needs to be three criteria met: 1) having a significantly low body weight as expected by their height; 2) having an intense fear of being fat that doesn’t go away with weight loss; and 3) having a distorted view of their own body size and shape, pointing out areas that they believe are fat. The patient will have OCD tendencies, insomnia, social withdrawal, and depression, and will be obviously underweight. Laboratory and physical findings include serum chemistry abnormalities, decreased WBC count, mild anemia, decreased thyroid hormone levels, osteopenia, and a slowed heart rate. There are two subtypes, depending on how they present themselves. Some are restrictive, others are binge/purging types, and others may be mixed in presentation. Those who fast, diet, and/or exercise are considered “restrictive,” while those who overeat and use vomiting and laxatives are “binge/purge” subtypes. There are many biological, psychological, and environmental causes that contribute to getting anorexia nervosa. These include the following: Psychological factors include excessive fear about the future, anxiety and depression, poor stress management, difficulty expressing emotions, OCD feelings, having perfectionistic tendencies, and being phobic about being fat. Environmental factors include hormonal changes at puberty, pressure or stress to be thin, bullying about body weight, bereavement or other 156

stressor, abusive relationships, and engaging in activities where thinness is idealized. Biological factors include being obsessive in childhood, brain abnormalities, developing an anxiety disorder in childhood, and having a family history of substance abuse, depression, and eating disorders. Anorexia nervosa is a leading cause of mental health-related death and many will not seek help independently. It takes several years of treatment to manage the disorder and there will be many relapses before a final cure is achieved. The disorder affects one in 200 women. Statistics in men are less well-known. Even with treatment, half of all people with the disorder will experience problems with food. Treatment involves several options. The first is psychotherapy, which can be one-on-one or in a group. Cognitive behavioral therapy is often employed as an option to help reorganize distorted thought patterns. Family-based therapy is used with adolescents who have the disorder. Medications include SSRIs, mood stabilizers, and antipsychotic medications. Olanzapine is often used to treat anxiety. SSRIs are the first-line drug of choice for the anxiety and depression associated with eating disorders.

BULIMIA NERVOSA (307.51) This is an eating disorder assigned to individuals who overeat on a regular basis and then use measures to prevent weight gain afterward, such as laxative abuse, purging, fasting, or overexercising. They feel out of control with how much food they consume that they will purge at a minimum of once weekly. It affects about 1.5 percent of women as a lifetime prevalence. It is mostly seen in young adults, rarely seen before puberty or after 40 years of age. It can follow a period of dieting or a stressful life event. The major symptoms of bulimia include being of a normal weight but perceiving themselves as being too fat. Other symptoms include overeating or an inability to stop eating, being excessively concerned with weight or body shape, compulsively exercising, vomiting after eating to get rid of eaten food, using diuretics or laxatives inappropriately, and having periods

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of fasting. They may overeat several times a day over many months and will often eat in secret. They are ashamed and disgusted by their bingeing behaviors and will seek to purge the food from their bodies, bringing a feeling of relief to the patient. Extreme exercising and visiting the bathroom right after eating is a feature of the disorder as they often vomit after eating. There are several things that must be met to make the diagnosis of bulimia nervosa. These include the following: 1) Eating more food in one sitting than most people would with an inability to control eating; 2) Recurrently taking steps to prevent weight gain by fasting, vomiting, and excessively exercising, using laxatives or diuretics; 3) Episodes of binge-eating and purging that occur at least once weekly for a minimum of three months; and 4) preoccupation with body weight and shape. It needs to be identified as separate from the behaviors seen in anorexia. The severity of the disease is specified at the time of diagnosis. Mild bulimia is 1-3 episodes per week; moderate bulimia is 4-7 times per week; severe bulimia is 8-13 times per week; and extreme bulimia is 14 times or more per week. There is no specific test for bulimia except for physical and dental examinations that will show signs of bulimia. There will often be calluses on the finger joints and dental caries from vomiting. There will also be signs of dehydration. Causes of bulimia include familial, psychological, genetic, and societal factors that work together to cause bulimic symptoms. Connections have been made between bulimia and low self-esteem, childhood sexual or physical abuse, dieting, and being involved in activities where weight is a major focus. People who embrace thinness as being the ideal body shape are at a greater risk of developing bulimia. There are usually comorbidities with bulimia, including anxiety and major depressive disorder. Many will have multiple psychiatric conditions that go along with the eating disorder. The onset of the other psychiatric symptoms may predate or postdate the bulimic symptoms. Substance

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abuse is a common comorbidity with bulimia with a third of all bulimics having alcoholism. PTSD is another common comorbidity. There are physical aspects and side effects to living with bulimia nervosa. These include blood sugar imbalances, nausea, vomiting, bloating, constipation, and abdominal pain. Hormones can be affected and sex hormones can decrease, leading to osteoporosis. There may be a decrease in thyroid hormones, affecting metabolism. There is no particular cure for bulimia but it can be treated. Therapy, medications, nutritional counseling, and medical/psychiatric monitoring need to take place. Treatment includes cognitive-behavioral therapy, acceptance and commitment therapy, dialectical behavioral therapy, psychodynamic psychotherapy, and family-based therapy. SSRIs are commonly used to treat things like depression, anxiety, and social phobia. Tricyclic antidepressants and topiramate can be used to decrease bingeing and purging cycles. About half of patients are symptom-free after five years following initiation of treatment.

BINGE-EATING DISORDER (307.51) This is an eating disorder that has compulsive overeating as the main symptom. The patient will eat long after they are full and when they aren’t even hungry. There are no purging behaviors; the patients may be normal weight, slightly overweight, and even obese. This is a new diagnosis under the DSM-V and involves a lack of self-control, usually starting in adolescence or early adulthood. Self-esteem and other psychological factors differentiate it from simple overeating. The episodes can occur several times per day or for several hours in any given day. Patients often have self-hatred over their inability to control their eating habits. The patient will often feel uncomfortably full and will be anxious or depressed, often refusing to eat in front of others. They will often say that they will diet after an episode and return to their destructive patterns of eating shortly after they quit eating. The patient often denies their behavior and lives in secrecy, being ashamed of their behavior. There is no simple diagnosis for the disorder

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and it is often a diagnosis of exclusion after other things have been ruled out. The exact treatments for binge-eating disorder have not been fully established as this is a new and separate disorder. DBT, behavioral weight loss, interpersonal psychotherapy, and cognitive behavioral therapy have all been tried and are being evaluated for the treatment of this disorder. CBT is the most widely-used therapy for binge-eating, while interpersonal psychotherapy helps the patient uncover the underlying roots of binge-eating. There are many comorbidities, including hypertension, personality disorders, bipolar disorder, and diabetes. A full medical workup is necessary as they have many medical issues as a result of their behaviors. There are many drug therapies that are being looked at, including antidepressants, anticonvulsants, and anti-obesity medications. Anticonvulsants that have been tried include zonisamide, which suppresses the appetite, along with SSRIs, such as fluoxetine and fluvoxamine. The overall prognosis is good if the patient is adequately treated.

OTHER SPECIFIED FEEDING OR EATING DISORDER (307.59) This disorder is known as OSFED, which replaces the “eating disorder not otherwise specified” category that existed in the DSM-IV. It involves those feeding and eating disorders that are serious but are not clearly anorexia nervosa or bulimia nervosa. It can involve any of the other feeding and eating disorders as well. There are five examples of OSFED, including atypical anorexia, limited duration bulimia nervosa, purging disorder, low frequency binge-eating disorder, and night eating syndrome. There is an unspecified feeding or eating disorder used to describe those who do not meet the criteria for any of the more obvious OSFED disorders. In atypical anorexia nervosa, there is a normal weight but all of the other criteria for AN are met. In atypical bulimia, the frequency is less than once a week or fewer than three months. Binge-eating disorder does not meet the time criteria for normal BED. In purging, purging is dominant; however, there isn’t binge-eating behavior. Night eating disorder involves eating mainly after awakening from sleep. The prevalence by age twenty years for OSFED was about 11 percent, split between the typical 160

OSFED disorders. The peak age at onset is about 18-20 years. There are still a number of patients that have EDNOS (eating disorder not otherwise specified) but the incidence of this disorder is decreasing with the new diagnosis of OSFED.

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KEY TAKEAWAYS •

The category of Feeding and Eating Disorders has been restructured in the DSM-V to include binge-eating disorder, OSFED, and rumination disorder.

•

Rumination disorder and pica are seen more often in children than adults but they can occur at any age.

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There are features similar in anorexia nervosa and bulimia nervosa but they have different etiologies and different manifestations.

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Patients with binge-eating disorder will overeat frequently but will not make efforts to purge or exercise.

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OSFED is a 5-category disorder that involves eating disorders that don’t fit with other known eating disorders.

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QUIZ 1. At what age is it appropriate to make a diagnosis of pica? a. Above age 2 years b. Above age 5 years c. Above age 12 years d. Above age 18 years Answer: b. It is probably appropriate to make a diagnosis of pica above age five years as eating non-nutritive substances below this age is developmentally appropriate. 2.

What is the upper age limit requirement for pica? a. 12 years b. 18 years c. 30 years d. There is no upper age limit Answer: d. There is no upper age limit for pica as it can occur in developmentally disabled adults at any age.

How long does pica have to last in order to make the diagnosis of this disorder? a. One week b. Two weeks c. One month d. Six months Answer: c. The eating of non-nutritive substances must last a minimum of one month in order to make the diagnosis.

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What is not considered a feature of avoidant restrictive feeding and intake disorder (ARFID)? a. Possible pain or difficulty with eating b. Distorted body image related to eating c. Aversion to social activities involving food d. Problems with the texture or smell of food Answer: b. These people will restrict their eating for a variety of reasons and will avoid social functions that involve eating but this is not due to any distortion of body image.

Which is not considered a risk factor for ARFID? a. Major depression b. Mother with eating disorder c. History of choking on food d. Autism spectrum disorder Answer: a. There is a variety of mental disorders and social or physical risk factors that increase the risk of developing ARFID; however, major depression is usually not a significant risk factor.

What is the ratio of females to males with anorexia nervosa? a. 2:1 b. 4:1 c. 10:1 d. 25:1 Answer: c. The ratio of females to males with anorexia nervosa is about 10:1. The exact incidence in males is somewhat unclear.

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What is considered a first-line drug of choice for the management of anorexia nervosa? a. Mood stabilizers b. SSRIs c. Atypical antipsychotics d. Benzodiazepines Answer: b. SSRIs are the first-line agents used to manage the anxiety and depression associated with patients who have anorexia nervosa.

What feature of bulimia is not seen in anorexia nervosa patients? a. Obsession with body weight and shape b. Over-exercising c. Lack of eating control d. Use of laxatives Answer: c. These things can be seen in both disorders; however, with anorexia, there is rarely a complete lack of control over eating as is prominent in bulimia nervosa.

How long do the symptoms of bulimia have to be present to make the diagnosis of the disorder? a. One month b. Three months c. Six months d. One year Answer: b. The symptoms must occur at least once a week for three months for the diagnosis of bulimia to be made.

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10.

Which type of OSFED disorder involves using laxatives and/or vomiting but does not include binge-eating behavior? a. Atypical anorexia nervosa b. Purging disorder c. Atypical bulimia disorder d. Night-eating disorder Answer: b. Patients who exhibit purging behaviors but do not have other anorexia or bulimia features, namely that of overeating, are said to have purging disorder.

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CHAPTER ELEVEN: ELIMINATION DISORDERS The focus of this chapter is elimination disorders. The DSM-V recognizes only three elimination disorders, including enuresis, encopresis, and other specified elimination disorder. These tend to occur in children but it is recognized that it is possible that it can occur in older people as well, especially if they have developmental disabilities. There can be physical, neurological, and psychiatric reasons behind having an elimination disorder, which will be discussed in this chapter.

ENURESIS (307.6) Enuresis involves the ongoing and persistent lack of ability to control urination that is inconsistent with one’s developmental age. This is common in children, affecting up to 10 percent of children. The most common type of enuresis is nocturnal enuresis. There are three main subtypes recognized by the DSM-V, which has widened the scope of the diagnosis. The three subtypes are 1) nocturnal (involving only nighttime wetting), 2) diurnal (involving only daytime wetting), and 3) nocturnal and diurnal (involving daytime and nighttime wetting). Nocturnal enuresis happens more commonly in boys with voiding occurring in the first onethird of the night. This could be caused by behavior (not eliminating before bedtime), elevated levels of anxiety and distress, or physical causes (incomplete filling of the bladder). Diurnal enuresis is more likely to occur in the afternoon when the child is in school or playing with others, which can be a source of significant embarrassment and bullying or teasing from peers. With nocturnal and diurnal enuresis, the occurrences of urination can occur at any time—day or night. The main symptom of enuresis is the elimination of urine, either voluntarily or involuntarily. It

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can be comorbid with various depressive or anxiety disorders, and is particularly comorbid with ADHD. Others will have insomnia. The behavior must occur twice a week for at least three consecutive months and should cause distress or impairment in functioning. It cannot be secondary to polyuria or a substance and cannot be due to a general medical condition. It cannot be diagnosed until the child is at least five years of age. Enuresis and encopresis are common under the age of five, before such behaviors are in complete control. As a child, the incidence is about 20 percent in five-year-old children but only about two percent in adulthood. Girls have more diurnal enuresis and boys, including adolescents, have more nocturnal enuresis. Twice as many adolescent boys will have nocturnal enuresis when compared to girls. Diurnal enuresis tends to occur when the child is too preoccupied to use the restroom. Many children with enuresis suffer from low self-esteem and their parents have an impairment in their quality of life because they worry about their child’s development and that something is wrong with their child. Sleep quality, academic performance, and overall health will decline as the disorder persists over time. This further decreases the quality of the family’s life. There are physical factors that play into having enuresis, including vasopressin release in sleep, small bladder size, bladder hyperactivity, and inability to fill the bladder completely during sleep. It can be triggered by increased stress, separation from the parent, the birth of a sibling, or some type of family dysfunction or conflict. ADHD children seem to have a high incidence of enuresis because of developmental issues. There are therapeutic measures taken to treat enuresis. There are moisture alarms that will alert the individual that they are starting to void. Synthetic vasopressin (called desmopressin) is a way to decrease the production of urine during sleep. Usually a combination of treatments is used with a great deal of family support. Alarm therapy has a higher dropout rate, while there are more relapses with desmopressin treatment. Behavioral therapy has also been found to be successful. The prognosis is good and it usually ceases by adolescence, regardless of treatment.

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ENCOPRESIS (307.7) Encopresis involves the repetitious passage of stool into inappropriate places (the floor or when dressed in clothing). It can be intentional or involuntary. Involuntary passage is often related to fecal impaction/constipation with diarrhea overflowing past the impaction. Things that are symptomatic of encopresis include the following: A. Secretive behavior about having a bowel movement B. Bowel incontinence C. Occasional passage of large stools D. Passage of stool in inappropriate places E. Hard stools or constipation The criteria for the disorder must all be met in order to make the diagnosis of encopresis: A. The child must be at least four years of age B. There must be repeated passage of stool in inappropriate places (clothing or floor, for example) C. One event per month must be present for a minimum of three months D. There cannot be laxative abuse or another medical disorder other than constipation There are two specifiers that must be used when making the diagnosis: 1) with constipation and overflow incontinence (as identified by physical exam or history) or 2) without constipation and overflow incontinence. The prevalence of encopresis in children aged five is about 1 percent, more commonly seen in boys than in girls. A mental age of four years must be reached. Children may have primary encopresis, in which they were never continent, or secondary incontinence, where it occurs after a period of continence. Voluntary encopresis is seen in conduct disorder and in oppositional defiant disorder. Soiling is done in anger toward authority figures. Children who play with feces tend to have deeper psychiatric issues.

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There are many risk factors linked to encopresis, including: A. Poor water intake B. High fat or high sugar diet C. Neglect or abuse D. Unstable life occurrences E. Fear of public bathrooms F. Constipation or painful defecation G. Lack of exercise H. Neurological impairment I. Neurocognitive delays J. OCD-related disorder K. Learning disabilities L. ADHD The treatment involves psychoeducation and training the child to have regular bathroom routines. Dietary and exercise changes can help as can using a chart to track the success rate. This can be difficult to treat because of problems with conduct, psychological problems, eating difficulties, and somatic problems. Family-based therapy and intervention can help resolve the problem. Routines and calming activities can help and comorbid conditions (anxiety, depression, etc.) need to be addressed. Biofeedback can help teach the child better sphincter control. Drug therapy involves using things to address the constipation including stool softeners, fiber, and certain laxatives. The goal is 1-3 bowel movements per day.

OTHER SPECIFIED ELIMINATION DISORDER (787.60 OR 788.39) This is a category of elimination disorder that is given to patients who have characteristics of encopresis or enuresis but do not meet the full criteria for the disorder. It can have a predominance of enuresis or encopresis, which changes the code given to it. The person giving the diagnosis must specify a reason why it is a specified diagnosis, such as low-frequency enuresis or similar atypical presentation. The code 788.39 is given to those with urinary 170

symptoms, while 787.60 is given to those with fecal symptoms.

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KEY TAKEAWAYS •

Enuresis involves the involuntary passage of urine, either diurnal, nocturnal, or both.

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Encopresis involves the involuntary or voluntary passage of stool in inappropriate places/times.

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Other specified elimination disorder involves an atypical presentation of either enuresis or encopresis.

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QUIZ 1. Which is not a type of enuresis? a. Paroxysmal b. Diurnal c. Nocturnal d. Diurnal and nocturnal Answer: a. Each of these is a recognized subtype of enuresis, according to the DSM-V; however, paroxysmal enuresis is not a subtype of this disorder. 2. When does nocturnal enuresis usually take place? a. Last third of the night b. Just before awakening c. In the first third of the night d. In the middle third of the night Answer: c. Most of the urination happens in the first third of the night. 3. When does urination usually happen in diurnal enuresis? a. Shortly after awakening b. In the morning c. In the afternoon d. In the evening Answer: c. Diurnal enuresis usually happens in the afternoon when the child is in school or is playing with peers, making it a frequent source of embarrassment and teasing.

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4. What is the prevalence of enuresis in adulthood? a. One out of 1000 b. 1 percent c. 2 percent d. 7 percent Answer: c. The incidence of enuresis is about 2 percent in adulthood. It is about 20 percent in kids aged five years. 5. What is the function of desmopressin in the treatment of enuresis? a. It stretches the bladder muscle b. It decreases bladder muscle irritability c. It increases arousal with a full bladder d. It decreases urine production Answer: d. Desmopressin is synthetic vasopressin that decreases urine production. It mainly treats nocturnal enuresis. 6. What is the main cause of involuntary passage of stool? a. Developmental rectal abnormality b. Fecal impaction c. Cognitive delay d. Diarrheal disorders Answer: b. Fecal impaction and severe constipation are the main cause of involuntary passage of stools in a child or adult with overflow around the impacted area.

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7. A specifier must be added to the diagnosis of encopresis. What does the specifier relate to? a. The presence or absence of constipation b. Whether the encopresis is voluntary or involuntary c. Whether solid or liquid stool is passed d. Regarding the frequency of the behavior Answer: a. The specifier relates to the presence or absence of constipation by history or physical examination. This indicates whether or not there is overflow incontinence. 8. What is the prevalence of encopresis in five-year-old children? a. 0.1 percent b. 1 percent c. 5 percent d. 10 percent Answer: b. The prevalence of encopresis in five-year-old children is about 1 percent. Some have primary encopresis, while others will have secondary encopresis. 9. What is least likely to be a comorbidity with encopresis? a. ADHD b. Obsessive-compulsive disorder c. Schizophrenia d. Oppositional defiant disorder Answer: c. Each of these is a risk factor and/or comorbidity with encopresis except for schizophrenia, which is rare in children to begin with.

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10. What is considered a first-line drug for individuals with encopresis? a. Sertraline b. Methamphetamine c. Atypical antipsychotics d. Stimulant laxatives Answer: d. The drug of choice would be a stool softener or laxative to resolve the constipation and to initiate regular trips to the bathroom.

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CHAPTER TWELVE: SLEEP WAKE DISORDERS Sleep-wake disorders include a variety of sleep-related medical and psychological disorders affecting adults and children. The most common disorder is insomnia disorder; however, there are people with hypersomnolence disorder, narcolepsy, and breathing-related sleep disorders like sleep apnea. There are a number of disorders classified as parasomnias, including nightmare disorder, sleep terrors, and sleepwalking. Restless legs syndrome is also listed in the DSM-V as a sleep-wake disorder.

INSOMNIA DISORDER (780.52) Insomnia disorder involves having recurrent poor sleep quality or quantity that interferes with daily life functions or that causes significant distress. It is the most common sleep-wake disorder. The individual can have difficulty getting to sleep, staying asleep, or have problems awakening in the early morning—unable to get back to sleep. These individuals are tired or sleepy during the day and will have inattention, difficulty concentrating, and irritability. About a third of adults have this problem with about 10-15 percent having daytime impairment. About 6-10 percent of people will meet the clinical criteria for this disorder. Typical symptoms include the following: A. Difficulty falling asleep B. Lying awake for extended periods of time C. Awakening several times per night D. Waking up early and being unable to get to sleep E. Not feeling refreshed after sleeping F. Fatigue or sleepiness during the day

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G. Difficulty focusing on a task H. Irritability The following DSM-V criteria must be met in order to have the diagnosis of insomnia disorder: •

Unhappiness with the quality or quantity of sleep, with varying abnormal sleep patterns

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The disturbance in sleep causes impairment in function, such as within the person’s job or personal life

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The difficult lasts at least three times weekly for a minimum three months

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There is opportunity to sleep but the problem persists

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The problem cannot be better explained by another physical, mental, or sleep-wake disorder

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The problem is unrelated to substance use or medication

The problem can be diagnosed with a variety of techniques that support the diagnosis, including the Epworth Sleepiness Scale and sleep diaries. Blood is checked for thyroid problems and other disorders and a physical exam is obtained. There is no single cause for the disorder; however, there are many contributing factors, including the following: •

Anxiety and stress can overstimulate a person, leading to negative associations with sleeping that may make it difficult to fall asleep or stay asleep.

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Having other sleep disorders that lead to insomnia, such as restless leg syndrome and sleep apnea.

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Mental disorders, such as depression and hormonal changes can contribute to insomnia, and vice versa.

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Chronic pain, arthritis, reflux, asthma, and thyroid problems can make it difficult to get to sleep or stay asleep.

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•

Medication or substance abuse, such as treatments for allergies, colds, thyroid disease, and hypertension are believed to cause insomnia as a side effect of the medications.

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Lifestyle factors, such as consuming alcohol or caffeine, working late from home, or exercising before bed can contribute to difficulty getting to sleep.

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There are many comorbidities with insomnia, including CAD, arthritis, fibromyalgia, diabetes, and COPD; with psychiatric disorders causing this, including bipolar disorder, anxiety disorder, and depressive disorder.

The differential diagnosis includes normal sleep variations that do not persist for three months or longer. These patients will not have daytime sleepiness nor adequate opportunity to sleep. Breathing-related sleep disorders often will lead to insomnia but are separate sleep disorders under the sleep-wake disorders category. Narcolepsy will share some features of insomnia but will have sleep-related hallucinations and sleep paralysis. People with certain parasomnias will have difficulty sleeping. The treatment of insomnia includes medications, such as hypnotic medications (eszopiclone, ramelteon, zaleplon, and zolpidem). These have varying effects on sleep production and maintenance. Sleep hygiene habits that can be changed should be changed. Cognitive behavioral therapy or CBT can help challenge negative beliefs around sleeping. Relaxation therapy, stimulus control therapy, and biofeedback can help induce relaxation and establish healthy sleep habits. Other things that can help include paradoxical intention (challenging sufferers to try to stay awake) and sleep restriction therapy (limiting time spent in bed to promote sleep deprivation). Usually two or more treatments are necessary.

HYPERSOMNOLENCE DISORDER (780.54) Hypersomnolence disorder is a new diagnosis in the DSM-V. It is one of ten sleep-wake disorders that include breathing-related sleep problems, restless leg syndrome, substance/medication-induced sleep disorder, and nightmare disorder. In this disorder, people

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tend to fall asleep unexpectedly. Sleep disorders like this can help general healthcare workers better understand and diagnose these types of disorders. Individuals with hypersomnolence will have extreme daytime sleepiness or excessive amount of sleep at night, although the sleep is not refreshing. They often doze off during the day and may experience depression and other physical symptoms. These include cognitive impairment, memory loss, irritability, loss of appetite, headaches, minor fevers, and depressed mood. The patient will have difficulty initiating and maintaining sleep and will have an unsatisfactory night’s sleep with frequent snoring. Because this does not have to be psychological or psychiatric, neurological and physical diseases that need to be ruled out as causative include brain tumors, chronic kidney disease, cancer, anemia, neurological disorders, fibromyalgia, and spinal cord disease. Each of these can disrupt sleep and can lead to hypersomnolence. In order to make the diagnosis, the symptoms must last for three months. Advanced testing must be done to rule in primary hypersomnolence disorders, such as narcolepsy and primary CNS hypersomnolence. Hypersomnolence can be post-infectious, post-traumatic, or periodic. There is a disease that is primarily seen in teen boys called Klein-Levin syndrome, which is very rare, affecting less than one in a million people. Symptoms include hypersomnolence and disturbances in cognition and behavior. Narcolepsy is a slightly more common hypersomnolence disorder, which is mostly a life-long condition. Comorbid conditions should be specified—both medical and psychiatric. Most cases of hypersomnolence disorder need pharmacotherapy as this is rooted in physical problems. Patients who have co-occurring depression and other psychological problems will benefit from psychological therapy. If no cause is found, the treatment focuses on symptomatology, such as Ritalin or other methamphetamine or amphetamine drug. Things like caffeine, alcohol, and nicotine are to be prohibited. Patients should also avoid sleep deprivation with naps during the day, if necessary. Driving while drowsy should be discussed and should be avoided.

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NARCOLEPSY (347.00) This is a neurological disorder that results in chronic hypersomnia. It starts in childhood but can be seen for the first time in young adults. Patients will get enough sleep at night but will still have excessive daytime sleepiness, often losing muscle tone suddenly and falling asleep at inappropriate times. They develop sleep behaviors that can be dangerous, depending on the situation, developing sudden onset of REM sleep. Strong emotional reactions can precipitate a sleep response. The labs in narcoleptics will show low levels of hypocretin, which is a neurologically-based protein that is linked to sleep and wakefulness. The EEG will show decreased REM activity during the night. Common features include hypnagogic hallucinations (upon sleep onset), hypnopompic hallucinations (upon awakening), and sleep paralysis. The main symptom is an irresistible need to sleep or sleep attacks that occur at any time. The episodes need to occur at least three times per week for three months to make the diagnosis. At least one of the following symptoms must be present: •

Episodes of cataplexy (loss of muscle tone) occurring several times per month lasting up to several minutes without loss of consciousness, often precipitated by a strong emotion.

•

In children or new-onset patients, they may have involuntary grimacing or jawopening with tongue thrusting motions.

•

Low hypocretin levels in the cerebrospinal fluid.

•

Nocturnal sleep polysomnography showing low REM sleep duration and rapid onset of REM sleep when falling asleep.

There are several specifiers that can be added, including “without cataplexy but with low hypocretin levels,” “with cataplexy but no low hypocretin levels,” “autosomal dominant cerebellar ataxia, deafness, and narcolepsy,” and others. There is a category called “narcolepsy

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secondary to another medical condition.” The severity can be specified, including mild (less than once a week), moderate (at least once a day), and severe (medication-resistant cataplexy with multiple daily episodes). The onset of narcolepsy is 7-25 years of age. About 8-12 percent will have a first-degree relative with the disorder and some can be autosomal dominant. There is a slightly higher prevalence in men. There are several comorbidities, including bipolar disorder, anxiety disorders, depression, schizophrenia, and obesity. Children with narcolepsy often gain a great deal of weight. While it is mainly treated with drug therapy, the patient with other symptoms may need cognitive behavioral therapy to deal with the lifestyle issues associated with the disease.

BREATHING-RELATED SLEEP DISORDERS Breathing-related sleep disorders include those sleep issues that are directly related to having some problem with breathing. Regardless of the problem, the patient has nighttime and daytime symptomatology that interferes with activities of daily living.

OBSTRUCTIVE SLEEP APNEA HYPOPNEA (327.23) This is a physical disorder in which soft tissues of the mouth and throat fall back into the air passages during sleep, obstructing the flow of air and resulting nocturnal shortness of breath and snoring. The patient will have repeated episodes of absent or shallow breathing while sleeping, despite making an involuntary effort to breathe. The O2 sat level will drop and the patient will have up to 40 seconds of apnea, after which they will frequently gasp and begin breathing normally again. The patient is unaware of the breathing problem; however, their sleep partner will often notice snoring and gaps in breathing. The patient may go for a long time without a diagnosis and will have excessive daytime sleepiness and fatigue with disturbed sleep. Most people will have minor sleep apnea, with a minority of patients having chronic, severe obstructive sleep apnea. Upper respiratory infections or tonsillitis can temporarily cause this problem and people who

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drink alcohol excessively will have an increase in sleep apnea. Obesity is a risk factor for this disorder.

CENTRAL SLEEP APNEA Central sleep apnea or CSA is another breathing-related sleep disorder in which the patient’s effort to breathe is decreased or absent for up to 30 seconds at a time, associated with a reduction in the O2 sat level during sleep. It is a brain-related disorder in which the patient’s respiratory centers fail to send out the signal to breathe. It is linked to Arnold-Chiari malformation in some cases. Pure central sleep apnea involves a decrease in the function of the brain’s respiratory centers. The stimulus of elevated CO2 levels will not turn on the center to breathe. The patient can awaken during an apneic spell and will feel a surge of panic when they cannot breathe and will have high CO2 levels at the time. After the apneic spell, breathing may be rapid in order to bring the CO2 levels into the normal range. This may happen during sleep or after the patient awakens during or shortly after an apneic spell.

SLEEP-RELATED HYPOVENTILATION (327.24) This is a breathing-related sleep disorder involving having an inadequate respiratory drive to breathe. Breathing is semi-automatic, meaning that the autonomic nervous system plays an important role with an override that is voluntary. The autonomic nervous system kicks in when we sleep so that we can continue to breathe involuntarily. In those with sleep-related hypoventilation, this mechanism breaks down frequently. There may be a comorbidity with sleep apnea but they are a separate disorder. Patients with sleep apnea will awaken because of hypercapnia and catch up their breathing. People with hypopnea will have shallow respirations for several seconds while sleeping. They may or may not wake up but will have elevated CO2 levels, slow heart rate, and low O2 levels.

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There are three specifiers in the DSM-V: The first is 327.24, which is idiopathic hypoventilation (and known known cause. The second is 327.25, which is congenital central alveolar hypoventilation, which occurs shortly after birth. The third is 327.26, which involves comorbid hypoventilation secondary to a substance or medical condition. The main substances seen with this disorder include alcohol, opioid drugs, and benzodiazepines. There is an obesity-related subtype; severity may also be a specifier. This disorder is mainly seen in those older than 50 years of age. Common comorbidities with this disorder include emphysema or COPD, hypothyroidism, neuromuscular disorders, cervical spine injuries, and chest wall disorders. Babies born with congenital central alveolar hypoventilation will have a lack of respiratory drive because of a lack of sensitivity to rising CO2 levels. Obesity is a common comorbidity as is substance abuse disorder. Treatment involves treating the comorbidity or underlying factors related to having this disorder.

PARASOMNIAS Parasomnias are a group of disruptive sleep disorders that happen when an individual has arousal during the REM or NREM sleep stages. They can result in a variety of undesirable behaviors, such as talking during one’s sleep or sleepwalking. These can occur in specific stages of sleep or during the sleep-wake transition. They can be disruptive to both the patient and anyone who sleeps with them.

CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS Circadian rhythm disorders represent disruptions in the circadian rhythm of the person’s schedule. There is a mismatch between the “internal body clock” and the external environment. People complain of insomnia at some times of the day and sleepiness at other times of the day that impact functioning.

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Examples of delayed circadian rhythm disorders include the following: •

Delayed sleep phase disorder—these individuals are “night owls” who cannot sleep until late and, as a result, they sleep in until late in the morning or early afternoon. This impacts normal morning functioning. This disorder can easily be mistaken for narcolepsy.

•

Advanced sleep phase disorder—these people have the opposite problem and will go to bed very early, awakening at 2-5 am. They will be tired in the late afternoon and early evening.

•

Jet lag—this problem stems from changing time zones and having difficulty adjusting to a new time zone after traveling. It is harder travel eastward than it is westward.

•

Shift work disorder—this problem involves having to rotate shifts or from doing straight night work. This will result in various types of sleep disturbances.

NON–RAPID EYE MOVEMENT SLEEP AROUSAL DISORDERS Non-REM sleep disorder involves either sleepwalking or night terrors. These patients will have incomplete awakening from sleep and will have a blank and staring face (with sleepwalking) and will be unresponsive to the environment. There will be amnesia for the episode and, within minutes after awakening, there is no impairment of behavior or mental activity. Sleep terrors are also non-REM sleep disorders in which there is a sudden arousal that awakens the person, who experiences panic and extreme fear. There will be autonomic evidence of fear with tachycardia, tachypnea, and diaphoresis. The individual is unresponsive to the efforts of others to comfort them during the episode. Both of these sleep disturbances can result in distress or impairment in functioning.

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SLEEPWALKING (307.46) Sleepwalking or somnambulism is combined sleep and wakefulness during slow-wave, or nonREM sleep. The patient will often do things they would during full consciousness but will be in a low-consciousness state that they don’t remember. Complex behaviors like driving, cooking, and homicide have happened when the patient was in a state of sleepwalking. The memory of the events during sleepwalking is poor to absent and, while the eyes are open, the expression is glazed over. It can last for up to 30 minutes. NREM sleep happens in the first third of sleep and this is when the activity happens. It happens usually once a night or less often. Features of the disorder include the following: •

Partial arousal during NREM sleep, usually in the first third of the night

•

Dream content that may or may not be remembered

•

Behavior consistent with the dream content that can be simple or complex

•

Impairment in environmental perception

•

Impaired judgment, problem-solving, and planning

•

Blank expression with dilated pupils

The individual is often confused after awakening but soon recovers normal functioning. While in a sleepwalking state, the individual may talk but does not make any sense. Children have less memory of their episodes than adults. The lifetime prevalence is 5-10 percent, being more common in children than adults, who have a prevalence of about 1.5 percent. Sleepwalking has an unknown cause but it may be genetic. Sixty percent of children who have two parents that sleepwalk will have the disorder themselves. It is believed to be autosomal dominant with incomplete penetrance. Sleepwalking can be due to medications, including benzodiazepines, other GABA agonists, antidepressants, antipsychotics, beta blockers, and sedative/hypnotics (like zolpidem) have an increased risk of causing sleepwalking. Parkinson’s disease will trigger sleepwalking in people 186

who never have done it before.

SLEEP TERRORS (307.46) Sleep terrors or “night terrors” are similar in origin to sleepwalking but with different behaviors. It is an arousal disorder in which the patient awakens partially from a non-REM sleep state. This usually happens in children who will awaken suddenly, scream or cry without consolation for up to 30 minutes. There are autonomic indications of fear as well. These things will only happen at night and will not happen during naptime. It usually occurs in the first third of the sleep period. Sleep terrors are not the same as awakening from a nightmare, even when they happen during deep sleep. The person awakening from a nightmare will be awake and will remember the nightmare. There may be fragments of a dream remembered in sleep terrors but not to the degree that they are remembered in a simple nightmare. The sleep terror individual cannot be consoled and will not be oriented. Nightmares occur in REM sleep and not in NREM sleep. Episodes of sleep terrors do not necessarily qualify as having sleep terror disorder; there needs to be marked distress and impairment for this to be a disorder. It cannot be secondary to drugs, medications, medical condition, or psychological problem. It is seen in early childhood and usually resolved by adulthood. Episodes can be seen in about 37 percent of those kids at 18 months, with a prevalence of episodes at about 20 percent by 30 months of age. Episodes can be seen in adults at a rate of 2 percent but this does not necessarily qualify as a disorder. There is no specific treatment for sleep terrors except engaging in better sleep hygiene. Most children outgrow the disorder with time. Adults with the disorder can undergo CBT to help them improve the quality of their sleep so they can have improved daytime functioning. The distress seen with the disorder can be seen by the parents of an affected child or by the sleeping partner if the individual is an adult. Things that should be ruled out include PTSD, which generally causes nightmares rather than true sleep terror episodes.

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NIGHTMARE DISORDER (307.47) This is also referred to as dream anxiety disorder. It is a DSM-V disorder given to individuals who have frequent severe nightmares. Nightmare disorder is a parasomnia, characterized by having abnormal experiences while falling asleep, waking up, or sleeping. While having nightmares is common and interrupt sleep, those with the disorder have frequent nightmares that occur during different aspects of sleep (going to sleep, between stages of sleep, or upon awakening). The prevalence is around five percent of the population. The patient with a nightmare awakens when the feeling of terror is at its greatest with a sense of panic. Orientation is fairly rapidly attained and the autonomic symptoms will begin to dissipate upon awakening. Things that precipitate nightmares include sleep deprivation and other psychological or medical conditions. Symptoms include having frequent episodes of disturbing dreams that awaken the individual, dysphoria around the content of the dreams, awakening with a clear recall of the dream, difficulty falling asleep after the episode, and episodes occurring in REM sleep (the last third of the sleep cycle). The diagnosis is made by patient history, including whether or not they use substances. A sleep diary may be necessary to make the diagnosis. EEG and sleep studies can be done if the diagnosis is in question. There are various medications that can cause nightmares, including antidepressants (SSRIs), barbiturates, beta blockers, and narcotics. Withdrawal from benzodiazepines, barbiturates, and alcohol can contribute to the presence of nightmares. Stress and anxiety can lead to nightmares. Trauma and PTSD are a major contributor to nightmares and affect up to 80 percent of people with PTSD. Nightmares are also associated with schizophrenia, major depression, borderline personality disorder, and individuals who are considered to be creative and/or artistic. There may be a genetic component to getting nightmares and individuals who eat at night (who may subsequently develop reflux) seem to be predisposed to getting nightmares. Things in the

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differential diagnosis include night terrors, PTSD-related sleep disturbances (which relate directly to the trauma), seizures, delirium, medications, and other brain disorders. The first-line drug treatment for nightmares is prazosin; however, other drugs have been employed, such as atypical antipsychotics, trazodone, gabapentin, cortisol, topiramate, phenelzine, and tricyclic antidepressants. Certain non-medical therapies can be tried, including CBT, image rehearsal therapy, self-exposure therapy, and lucid dreaming therapy. Some patients resolve their symptoms with hypnosis or with progressive deep muscle relaxation techniques.

RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER (327.42) This is a parasomnia also referred to as RBD. It involves having a lack of the normal muscle atonia that happens when a normal person dreams. These people will act out their dreams and may injure themselves or their sleeping partner. It can be as simple as minor muscle twitching or as complex as actively reaching for and grabbing their nocturnal partner during the dream state. It affects about 0.5 percent of the population. Most people with this disorder are middle-aged to older males that are in the early stages of some type of neurodegenerative disorder (including Parkinson’s disease or other dementia). The symptoms occur during REM sleep about 90 minutes after sleep onset or in the early morning hours. It is seen also when napping during the day. The patient does not awaken with confusion or disorientation. The patient will not have substance abuse or coexisting mental disorders associated with this. There is no obvious cause of the disorder. Sleep studies can define the presence of the disorder. The drug of choice for RBD is clonazepam, which has a success rate of 90 percent, with symptoms improving within a week of choice. Symptoms return after a while, even on medications. Some patients will improve with tricyclic antidepressants. There are no nonmedicinal or psychotherapeutic treatments for this disorder.

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RESTLESS LEGS SYNDROME (333.94) Restless legs syndrome or RLS is a DSM-V sleep-wake disorder that involves having an uncomfortable, creeping, tingling, or crawling sensation on the legs that is only relieved with moving the legs. This results in a continual urge to move one’s legs. It usually starts in the evening, particularly around sleep time. The patient will be unable to sleep because of a need to move their legs. It is related to anxiety or to a medical problem, and results in poor sleep maintenance, daytime fatigue, and non-restorative sleep. There are five criteria for the disease, including the following: •

The urge to move the legs with uncomfortable leg sensations relieved partially by moving them.

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Symptoms occurring three times weekly for a minimum of three months.

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Distress or impairment in functioning

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A lack of another disease that could explain the symptoms.

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A lack of drug use or alcohol use explaining the symptoms.

The typical age at onset is in the 20s and 30s, with worsening symptoms with age. It is not often seen in children (with about a two percent incidence in children). The overall prevalence is 2-7 percent, with a slight preponderance of women at 1.5-2 times more than men. It increases with a family history of the disorder and in pregnancy. There are several brain pathways and systems suspected as being causative. Typical comorbidities include depressive disorders, anxiety disorders, and things like ADD/ADHD. Migraine headaches increase the prevalence of restless legs syndrome, as does bruxism. Treatment for RLS will also treat bruxism symptoms. A total of 80 percent of people with RLS will have Periodic Limb Movement Disorder (PLMD), in which sleep is disrupted by the presence of twitching or jerking movements of the extremities.

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In treating restless legs syndrome, patients are instructed to walk, massage their legs, stretch, or apply hot or cold packs to the affected legs. Dopamine agonists, such as those used in Parkinson’s disease, benzodiazepines, and opiates, have been used to treat this disorder (as they can induce sleep). Flexeril and other muscle relaxants can help. Those who aren’t treated may have daytime fatigue and functional impairment during the daytime hours because of a lack of restful sleep. Things to consider in the differential diagnosis include peripheral neuropathy, arthritis, and lower extremity edema. Anxiety can cause these symptoms as well.

SUBSTANCE/MEDICATION-INDUCED SLEEP DISORDER Substance/medication-induced sleep disorder can involve any severe sleep problem, including insomnia or hypersomnia, associated with the taking of or the withdrawal from a substance. The substance can be tobacco, cocaine, stimulants, opiates, sedatives, caffeine, alcohol, and other drugs. The problem cannot be secondary to another sleep disorder and must cause either distress or difficulty in functioning. People with other sleep disorders will have an increased risk of this problem secondary to selfmedicating another sleep issue. The same is true for those with mental health problems, such as bipolar disorder, depression, or anxiety disorders. Many other individuals with medical conditions of varying kinds can use substances that lead to a substance-related sleep disorder. Stopping the medication will usually resolve the problem.

OTHER SPECIFIED INSOMNIA DISORDER (780.52) This is the category that applies to presentations in which there is significant distress or life impairment that predominate but don’t meet the full criteria for any particular sleep-wake disorder. The clinician has the opportunity to state exactly why the disorder does not meet traditional criteria. This is usually accomplished by recording “other specified insomnia disorder” followed by the specific reason, such as brief insomnia disorder. It can involve a severe disorder of short duration or atypical presentation.

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UNSPECIFIED INSOMNIA DISORDER (780.52) This is the diagnosis given when there is not enough evidence to state that the patient meets all the criteria for insomnia disorder or even for other specified insomnia disorder. This is a catchall category that is not frequently used, given there are better options for diagnosing insomnia.

OTHER SPECIFIED HYPERSOMNOLENCE DISORDER (780.54) This is similar to other specified insomnia disorder in which the patient has distress or impairment because of hypersomnolence but does not fit the time requirement for hypersomnolence disorder or doesn’t have the typical presentation. The clinician can specify why the criteria cannot be met.

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KEY TAKEAWAYS •

There are many sleep-wake disorders, of which insomnia disorder is the most common.

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Patients can have lack of sleep or too much sleep or lack of restorative sleep that causes distress or impairs some aspect of life functioning.

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Parasomnias represent several disorders, including somnambulism, sleep terrors, and nightmare disorder.

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Several breathing-related sleep disorders have their origin in physical and not psychological problems.

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QUIZ 1. What is considered the most common sleep-wake disorder? a. Restless legs syndrome b. Insomnia disorder c. Sleep apnea d. Hypersomnolence disorder Answer: b. About a third of adults will have some type of insomnia with 6-10 percent meeting the clinical criteria for the disorder. 2. How long must the symptoms of insomnia disorder occur for the diagnosis to me made under the DSM-V criteria? a. One week b. One month c. Three months d. Six months Answer: c. The symptoms must occur at least three times a week for three months to make the diagnosis. 3. What is not a common comorbidity with insomnia disorder? a. COPD b. Arthritis c. Bipolar disorder d. Hypersomnolence disorder Answer: d. Patients with many physical and mental disorders will have difficulty with sleeping; however, hypersomnolence disorder is not often comorbid with insomnia disorder.

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4. What is not a feature of narcolepsy? a. Hypnagogic hallucinations b. Sleep paralysis c. Restless legs syndrome d. Hypnopompic hallucinations Answer: c. Patients with narcolepsy can have any of these features except for restless legs phenomena. 5. How long do the symptoms of narcolepsy or hypersomnolence have to occur before making the diagnosis, according to the DSM-V? a. Two weeks b. One month c. Three months d. Six months Answer: c. The patient must have the symptoms of hypersomnolence or narcolepsy for three months before the diagnosis can be made. Narcoleptic symptoms must happen at least three times a week. 6. What is not a risk factor for obstructive sleep apnea? a. COPD b. Upper respiratory infection c. Obesity d. Alcohol use Answer: a. Each of these is considered a risk factor for obstructive sleep apnea except for COPD.

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7. When does sleepwalking tend to occur in a susceptible individual? a. In the first third of the night b. In the middle of the night c. In the early morning hours d. Right after falling asleep Answer: a. Sleepwalking occurs in a susceptible individual in the first third of the night, when non-REM sleep is most likely to occur. 8. Which drug is least likely to contribute to sleepwalking behaviors? a. Sedative hypnotics b. Beta blockers c. Atypical antipsychotics d. Lithium Answer: d. Each of these can contribute to sleepwalking behavior; however, mood stabilizers like lithium are not typically associated with this disorder. 9. What is not a difference between sleep terrors and nightmares? a. Nightmares are more easily recalled b. Nightmares occur in REM sleep, while sleep terrors occur in NREM sleep c. There is less autonomic arousal in sleep terrors than nightmares d. Nightmares can occur at any age, while sleep terrors happen in children Answer: c. There is autonomic arousal with both nightmares and sleep terrors; however, the arousal persists for longer in sleep terrors.

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10. How often do symptoms of restless legs syndrome have to occur before the diagnosis can be made? a. Five times a week b. Three times a week c. Once a week d. Twice a month Answer: b. The symptoms of RLS must be present at least three times a week for three months to make the diagnosis of the disorder.

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CHAPTER THIRTEEN: SEXUAL DISORDERS This chapter is about sexual disorders, which include those related to otherwise normal human sexuality. Men may have erectile disorder, delayed ejaculation, hypoactive sexual desire disorder, and premature ejaculation, while women can have female orgasmic disorder, female arousal disorder, and genito-pelvic pain/penetration disorder. Both men and women can have gender dysphoria or sexual dysfunction related to the use of a substance or substances.

DELAYED EJACULATION (302.74) Delayed ejaculation or DE is a sexual disorder in which the man is unable to have an ejaculation after 30 minutes of continuous sexual stimulation. It can also be referred to as retarded ejaculation, inhibited ejaculation, or delayed orgasm. There are multiple causes, including anxiety about sex, religious or cultural issues, and sexual trauma. Anxiety and depression can lead to this as well as various medications especially SSRIs and excessive alcohol use. Physical causes include hypothyroidism, coronary artery disease, surgical or injury-related trauma, low testosterone, and urinary tract infections. Delayed ejaculation is unrelated to erectile dysfunction in most men. It can cause a great deal of sexual dissatisfaction, anxiety, and frustration with sex that can lead to conflict with one’s romantic partner. There are four basic symptoms and seven different specifiers. The four symptoms identified by the DSM-V include the following: A. Inability to have an orgasm between 75 percent and 100 percent of the time, with either delays or absences in ejaculation. B. Symptoms present for six months. C. Symptoms cause distress in the patient.

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D. The symptoms cannot be secondary to a medication or substance. The seven specifiers include having lifelong dysfunction, acquired dysfunction, generalized to all sexual situations, situational, and three degrees of severity, including mild, moderate, or severe. The onset can be since sexual activity began or acquired with age. Older men have lower testosterone levels and resultant prolonged ejaculation times. This is the rarest sexual complaint in men and is not well understood. Risk factors include having an idiosyncratic masturbation style (that isn’t replicated with a sexual partner), fear of impregnating a woman, and overexposure to pornography. Sexual trauma and having certain cultural or sexual prohibitions can result in delayed ejaculation. This disorder is comorbid with major depressive disorder. Treatment includes CBT, couples’ counseling, and psychodynamic therapy (depending on the cause). The major complication of this disorder is difficulty with conception.

ERECTILE DISORDER (302.72) Erectile disorder involves the inability to achieve or maintaining an erection during sex. It affects up to 18 percent of men at some time in their lives. According to the DSM-V, it cannot be an occasional problem and is not considered erectile disorder if it doesn’t cause distress or difficulty with a partner. It cannot also be secondary to an exclusively physiological problem like a medical condition or substance abuse. Symptoms include being unable to achieve an erection during sexual activity, difficulty maintaining the erection, or having a soft erection. These symptoms must last for six months and has specifiers to include generalized or situational dysfunction as well as mild, moderate, or severe disease states. The most commonly affected person is a man over the age of 50 years. Other pathologies need to be ruled out before it can be called erectile disorder. Treatment involves changing lifestyle, such as eating nutritiously, avoiding tobacco, avoiding alcohol, sleeping better, and getting enough exercise. Psychotherapy is indicated if there is no biological cause for the disorder. Couples’ counseling may be indicated. Psychoeducation and 200

cognitive interpersonal treatment can be helpful in some cases. If there is a mood disorder, this can be treated with medications. Sex therapy is sometimes recommended. Medications are increasingly used, particularly phosphodiesterase inhibitors like Cialis, Levitra, and Viagra. These can be used when there are no medical contraindications to taking the drugs.

FEMALE ORGASMIC DISORDER (302.73) This is an extremely common sexual dysfunction, affecting up to 42 percent of women at some point in their lives. There can be a delay in getting an orgasm, reduction in orgasmic intensity, or absence of an orgasm. This can be related to relational problems, depression, stress, anxiety, medications, and chronic medical conditions. The symptoms must last for six months and should be unrelated to other mental, physical, or relational problem. It can be primary, in which the woman has never had an orgasm, or secondary, after a period of normal sexual experiences. It can be met with frustration or mild distress. The disorder diagnosis depends on there being distress with the symptoms. The causes are multifactorial. It can be related to partner problems (poor health of the partner or poor relationship), lack of understanding of female sexual satisfaction, poor body image, sexual abuse, anxiety, and depression. Lack of sexual experience can contribute to this problem. Physical problems, including thyroid problems, heart disease, asthma, MS, and pelvic disorders, can be causative. Drugs that inhibit orgasm include SSRIs, antipsychotics, mood stabilizers, heart-related drugs, and chemotherapeutic drugs. There may be a genetic factor involved, although getting this kind of history can be difficult. This is the second most prevalent sexual disorder (after hypoactive sexual desire disorder), affecting up to 28 percent of women at any given point in time. There is a high rate of comorbidity with other sexual disorders, particularly with sexual arousal and sexual pain disorders. Anxiety and depression are frequent comorbidities with half of all women with the disorder meeting the criteria for a depressive disorder. Treatment involves couples’ therapy, cognitive behavioral therapy, psychoeducation to include

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masturbation training, and mindfulness or yoga interventions. For women who develop this around menopause, hormonal replacement therapy can be effective in restoring normal orgasmic activity.

FEMALE SEXUAL INTEREST/AROUSAL DISORDER (302.72) This is a complicated and little understood condition affecting many women. It is due to a wide range of factors, which may be biological, social, environmental, psychological and/or hormonal. There are many comorbidities, including bipolar disorder, phobias, depression, panic disorder, and anxiety disorders. It is defined as a complete lack of or decrease in sexual interest or sexual arousal. It can include an absence of fantasizing or erotic thinking with no or little pleasure found in sexual activity. The symptoms must occur for six months to make the diagnosis. It is rarely due to a physical or substance-related cause and is most commonly psychological. It can be primary or acquired and may be mild, moderate, or severe. Distress must be present to make the diagnosis. Treatment can include the use of the Eros Clitoral Therapy Device, which increases arousal by increasing clitoral blood flow. Lubricants of certain types can also be helpful. Healthier lifestyles, including stopping alcohol, cigarettes, and caffeine can help as well. Stopping some prescription drugs will make a difference, depending on the situation. Exercise can improve libido and will combat the stress that can play a role in hypoarousal. Psychotherapy or psychoeducation in some cases will be helpful.

GENITO-PELVIC PAIN/PENETRATION DISORDER (302.76) This disorder involves a tightening of the vagina (vaginismus) whenever there is an attempt to penetrate it. It is completely involuntary and affects more than just intercourse. Gynecological exams and tampons are difficult or impossible; there is pain when attempting to enter the vagina because of the muscle spasm. The pain can be mild to severe as some women can use tampons but cannot have sexual intercourse. This disorder was formerly called vaginismus.

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Symptoms include having one or more of the following criteria: A. Tightening of the vaginal muscles with attempts at penetration B. Tension or pain when penetration is attempted C. Low desire to have intercourse D. Avoidance of sexual activity E. Intense phobia of vaginal penetration The cause of this disorder is unclear. It could be physiological and may involve inflammation or injury to the vaginal muscles. It can be psychological, secondary to a prior traumatic experience such as abuse or painful childbirth, or secondary to nerve-related hypersensitivity. Fear of pregnancy can contribute to this disorder as well. It can be primary, acquired, or situational in nature. It can be triggered by vigorous physical activity of any kind. A complication of this disorder can be depression, especially as it interferes with relationships and childbearing efforts.

MALE HYPOACTIVE SEXUAL DESIRE DISORDER (302.71) This disorder requires the single criterion of being male and having a low desire for sex that causes distress and is not related to a substance, medical illness, or other psychological disorder. This is a new disorder to the DSM-V, that previously did not separate the sexes in hypoarousal disorders. Its prevalence in men is about 15 percent. The DSM-V requirements for the disorder include having the symptoms for six months at least 75 percent of the time. There will be low sexual desire and a decreased ability to have an orgasm with premature ejaculation as a common feature. It needs to cause distress or problems with interpersonal relationships in order to qualify as having the disorder. The disorder can be related to comorbid depression, andropause, and anxiety. The levels of both estrogen and testosterone will influence sexual desire in men. Having interventions for cancer (especially related to prostate cancer or other pelvic-related cancer) can decrease a man’s sexual arousal levels. Spinal cord disorders or procedures can affect sexual desire. Other 203

biological causes include vascular diseases, neurological diseases, smoking, medications (such as SSRIs and antihypertensives), and alcohol abuse. Psychological factors involve sexual abuse/rape, relationship issues, exhaustion, stress, and mental illness. Depression must always be screened for as this is a highly-correlated factor. The different treatments for male hypoactive sexual desire disorder include psychotherapy and hormone replacement therapy with testosterone. There are several ways to get testosterone, including by skin patch, creams, or suppositories. Mindfulness techniques will help in psychologically-based cases. Drugs that may also help but are less shown to be beneficial include bupropion, olanzapine, and phosphodiesterase-5 inhibitors like tadalafil and sildenafil.

PREMATURE (EARLY) EJACULATION (302.75) Premature ejaculation is defined as early ejaculation during vaginal intercourse (but not for other types of sexual activity). It involves ejaculating within one minute of vaginal penetration. The man feels unable to control his ejaculation and is frustrated by the event. Causes can be related to self-esteem, anxiety, penile hypersensitivity, and inexperience in sexual matters. Worry about the woman achieving orgasm can actually make the problem worse so that it becomes a conditioned response. While there is a strict definition of premature ejaculation, it can be more loosely defined as having a lack of control over ejaculation that is unsatisfying to the other person. The average time in normal males is three minutes. The disorder must persist for a minimum of six month and must be experienced at least 75 percent of the time. It should be distressful or frustrating and cannot be caused by another mental disorder, medication, or medical problem. There are several specifiers to consider, including primary or lifelong, acquired, generalized, and situational, with mild, moderate, or severe disease (based on how long it takes to have an ejaculation after penetration). The prevalence is 1-3 percent in the US. The major risk factors for premature (early) ejaculation include anxiety disorder (particularly social anxiety disorder) and PTSD from sexual trauma. There is a frequent comorbidity with

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erectile dysfunction. Treatment involves psychosexual education, SSRIs, and benzocaine topical anesthetic (which can decrease the sensitivity of the penis) and will delay ejaculation. Because this happens to young men primarily, there can be a short latency period, after which the man can attempt to have an erection again.

SUBSTANCE/MEDICATION-INDUCED SEXUAL DYSFUNCTION (VARIOUS CODES) This involves any type of sexual dysfunction caused by alcohol or drug use. It can affect men or women and can interfere with the experience of sexual pleasure to the individual or their sexual partner. The problem must not be occasional but must last at least six months and must be frequent enough to cause distress or interpersonal problems. In addition, the problem must not have been there before the use of the substance felt to be responsible for the disorder. The problem can be present during intoxication (actively taking the drug and being under the influence of it). It can also happen during withdrawal from the drug but will improve after the withdrawal phase is completed. It can persist after withdrawal, but this would be rare. If a month goes by and the sexual problem persists after stopping the drug, it is probably not substance-related. Drugs that can cause this include alcohol, opioids, sedatives, benzodiazepines, amphetamines, and cocaine. Cannabis is not listed in the DSM-V; however, some believe it can impair sexual functioning nevertheless. Many drugs taken for mental illnesses will have sexual side effects. In fact, this is a major contributor to these patients stopping their drugs without talking to their doctor or psychologist. This tends to worsen the prognosis for patients who do this. On the other hand, people who take a lot of medicines for physical illnesses will have an improvement in their sexual dysfunction with an adjustment or reduction in dose of the medications they take.

GENDER DYSPHORIA (302.85) Gender dysphoria is not classically a “sexual disorder” and is a new addition to the DSM-V, replacing “Gender Identity Disorder.” The new term was introduced in order to exclude people

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who believe they are the opposite gender that they were assigned and are not dysphoric about it. It involves teens and adults who are fixated by their gender and often feel as though they are not the right gender. They have significant distress and problems with interpersonal relationships because of their gender fixation. This can occur in children but does not always translate to cooccurrence in adulthood or as an adolescent. The major feature of gender dysphoria is an incongruence between the gender the person believes they are and what society believes them to be. It must last a minimum of six months and should consist of two or more of the secondary criteria, including the following: A. Intense need to get rid of secondary or primary sex features or to delay their maturation. B. Intense desire to have the sex features of the other gender. C. Desire to transform to the other gender. D. Need to be treated by society as belonging to another gender. E. Having the characteristic feelings and responses of the opposite gender. F. The problem should cause distress and impairment in major areas of life. The disorder is 2-4.5 times more prevalent in boys than it is in girls but this equals out when the person becomes a teenager. The prevalence is very rare, however, affecting 0.002-0.014 percent of individuals. There is no evidence that psychotherapy will change the patient’s inclination but it can help with coexisting depression and suicidality. Not everyone wants sex reassignment surgery and some will be content to cross-dress. The treatment often offered include psychotherapy to deal with the various issues that come up, pharmacological treatment, and sexual reassignment surgery. Often, all of these modalities are used to help the patient who wants to transition be able to successfully do so. Family and couples’ therapy may also be options. Speech therapy can help the patient learn to speak more like the opposite gender. Medications basically involve hormonal therapy, such as LHRH agonists, progestins, flutamide, spironolactone, and cyproterone acetate. Estrogen is used for breast development in males 206

transitioning to females, while testosterone is used for body hair development in females transitioning to males. Sexual reassignment therapy has a high satisfaction rate; however, its use in adolescents is controversial.

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KEY TAKEAWAYS •

Sexual disorders primarily involve difficulties with sexual interest, arousal, orgasms, and ejaculation.

•

Sexual disorders can be physical, social, psychological, or hormonal.

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There are many substances that affect sexual arousal and performance, leading to several DSM-V substance or medication-induced sexual dysfunction.

•

Gender dysphoria is a new DSM-V category that involves an incongruence between one’s actual gender and the gender they would rather be.

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QUIZ 1. If a man is unable to ejaculate after what period of time of continuous stimulation is he diagnosed with delayed ejaculation? a. 15 minutes b. 30 minutes c. 45 minutes d. 60 minutes Answer: b. Continuous stimulation that fails to lead to ejaculation after 30 minutes is referred to as delayed ejaculation. 2. What is not another name given to delayed ejaculation? a. Incomplete ejaculation b. Retarded ejaculation c. Inhibited ejaculation d. Delayed orgasm Answer: a. Each of these is another name given to delayed ejaculation except for “incomplete ejaculation.” 3. How long do the symptoms of erectile disorder need to be present in order to make the diagnosis? a. One month b. Three months c. Six months d. One year Answer: c. The symptoms must be present for about six months or longer in order to make the diagnosis of erectile disorder.

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4. What is the approximate lifetime prevalence of female orgasmic disorder? a. 5 percent b. 10 percent c. 20 percent d. 40 percent Answer: d. The lifetime prevalence of female orgasmic disorder is about 42 percent, making it an extremely common sexual disorder. 5. Which of these is most related to genito-pelvic pain/penetration disorder? a. Dyspareunia b. Dysmenorrhea c. Hypoarousal disorder d. Vaginismus Answer: d. Vaginismus is the former name for genito-pelvic pain/penetration disorder but the name has been changed as of the writing of the DSM-V. 6. What is the approximate prevalence of male hypoactive sexual desire disorder? a. 1 percent b. 5 percent c. 15 percent d. 25 percent Answer: c. The prevalence of this disorder in men is about 15 percent. This comes from more recent research that has begun to look into the hypoarousal states in men and women.

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7. Premature ejaculation is defined as having an orgasm and ejaculating within what timeframe after vaginal penetration? a. One minute b. Three minutes c. Five minutes d. Ten minutes Answer: a. Premature ejaculation is defined as having an orgasm and ejaculating within a minute of vaginal penetration. 8. What is a first-line medical treatment for premature ejaculation? a. Phosphodiesterase-5 inhibitors b. Mood stabilizers c. Testosterone replacement d. SSRIs Answer: d. SSRIs will inhibit ejaculation and will prolong the time it takes to reach orgasm in the male with early ejaculation problems. 9. Which drug is not listed as causing sexual dysfunction in the DSM-V? a. Opiates b. Cocaine c. Marijuana d. Benzodiazepines Answer: c. Marijuana may affect sexual functioning but it does not have a category for causing sexual dysfunction in the DSM-V.

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10. What is the major feature necessary in gender dysphoria? a. Distress or impairment in daily functioning because of gender b. Intense incongruence between the person’s gender and the gender they see themselves as. c. Need to be treated by society as the opposite gender. d. Disgust with one’s sexual characteristics. Answer: b. The individual must have incongruence between the person’s gender and the gender they see themselves as. The other features may be present but are not the primary criterion.

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CHAPTER FOURTEEN: DISRUPTIVE, IMPULSE CONTROL, AND CONDUCT DISORDERS The main topic of this chapter is disruptive, impulse control, and conduct disorders, which can affect children, adolescents, and adults. These include oppositional defiant disorder, intermittent explosive disorder, conduct disorder, and antisocial personality disorder. This classification of DSM-V disorders also includes pyromania and kleptomania. The DSM-V includes, in addition, a special category for other specified disruptive, impulse control, and conduct disorders.

OPPOSITIONAL DEFIANT DISORDER (313.81) While all children can be oppositional at times, and while this is normal development for a 2-3year-old child and young, adolescent, individuals with ODD (oppositional defiant disorder) will be openly uncooperative and hostile on a regular and consistent basis. This affects the child’s family, social, and school life. Their openly defiant and uncooperative behavior towards authority that is a serious interference in the child’s and family’s lives. Common symptoms include the following: A. Questions and disobeys rules B. Frequent temper tantrums C. Arguing with adults D. Deliberate attempts to upset or annoy others E. Blaming others for his or her mistakes or bad behavior F. Anger and resentment on a regular basis G. Behaves and talks in meanly when aggravated H. Frequently seeks revenge and has a spiteful attitude 213

This tends to be most noticeable at school or at home. About 1-16 percent of all children under the age of 18 years will have this. While no one knows the cause of ODD, these children were more demanding and rigid at an early age—indicating a biological origin. This is a disorder that is reserved for children under the age of 18 years exclusively. In order to have the diagnosis, the behavior must be consistent and damaging to the child’s welfare. There are many comorbidities with these children, including ADHD, bipolar disorder, depression, anxiety disorders, and learning disabilities. The coexisting disorder needs to be treated if there is hope to treat the ODD. Some will not be treated, with an increased risk of conduct disorder later in life. The treatment of ODD may include individual psychotherapy to manage anger, parent management training programs to help parents manage their child’s unwelcome behavior, and family therapy to improve interpersonal communication. Social skills training can be done to improve social skills and to decrease interpersonal problems with peers. Cognitive training regarding problem-solving can also help the child. Medications are directed at managing the comorbid conditions. This is why a comprehensive evaluation needs to be done on children suspected of having ODD.

INTERMITTENT EXPLOSIVE DISORDER (312.34) This is defined by the DSM-V as having “recurrent behavioral outbursts representing a failure to control aggressive impulses.” It is a diagnosis that can be made in anyone six years of age or older. Many types of aggressive outbursts can happen with this disorder, which needs to be consistently occurring in order to make the diagnosis of IED. People who are at risk include former military personnel, individuals with a history of trauma, and those who are morbidly obese. The behavior must lead to relationship, occupational, and social problems in order to make the diagnosis. The main symptom of IED is the presence of frequent impulsive and aggressive outbursts, which can be verbal or physical. They are difficult to predict and happen with little or minor

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triggers. It must occur twice a week for at least three months to make the diagnosis. Some explosive outbursts are normal and common, with a prevalence of the actual disorder being about 8 percent of young people. It is usually seen in those under 40 years of age but can be diagnosed at any age. The consequences of intermittent explosive disorder are great. It is the underlying factor in domestic violence, property damage, road rage, and child abuse. There are severe relationship problems because of this and there may be serious legal consequences if there is injury to property or other persons. The onset of IED happens at around the age of twelve but can be seen in kids as young as six years old. Besides the military and obese individuals, those who’ve been subjected to physical abuse, child abuse, assault, and human rights violations are at a high risk. The use of alcohol will exacerbate the disorder. Comorbidities include PTSD, depressive disorders, substance use disorders, borderline personality disorder, and antisocial personality disorder. The goal of treatment is remission in which few symptoms persist. The patient generally doesn’t seek help themselves but are court-ordered or encouraged to seek help by loved ones. There is poor insight into the problem and blaming often occurs. The person sees aggressive behavior as a strength rather than a weakness. The therapist is not often seen as a supportive person. Mood stabilizers and antidepressants are often used because therapy isn’t always successful. The overall prognosis for the disorder is reasonably good with an average disease duration of 12-20 years. The numbers of aggressive outbursts in general will decrease as the person ages. Those who seek treatment can learn anger management, stress management, and positive coping skills.

CONDUCT DISORDER (312.81) Conduct disorder or CD is generally a disorder of individuals under the age of eighteen years who do not conform to societal or legal norms as would be appropriate for their age. It is also 215

referred to as “juvenile delinquency” and usually comes to the attention of the juvenile justice system or the school system. This is considered a precursor disorder for antisocial personality disorder, especially in those who show no emotion or who are extraordinarily callous. The comorbidity most commonly seen with this is ADHD because these individuals are often bullied or mistreated by peers, putting them at risk for conduct disorder and adult criminality. Oppositional defiant disorder may be a preexisting condition and both diagnoses can be made in the same individual. The rate of adult criminality in those with conduct disorder is about 50 percent. To make the diagnosis, the DSM-V requires at least four of the following symptoms to be present: A. Frequent physical altercations B. Usage of a weapon to hurt others C. Aggressive behavior toward others D. Deliberate physical cruelty to others E. Cruelty to animals F. Involvement in a violent crime, such as mugging G. Forces sex upon another H. Arson causing property destruction I. Property destruction through other mechanisms J. Non-confrontational crime, such as breaking and entering K. Retail theft behavior L. Curfew disregarding prior to the age of 13 M. Has been truant before thirteen years of age N. Has run away from home at least twice The only time it is diagnosed in those older than eighteen years of age is when the full criteria for antisocial personality disorder is not met. The behaviors must cause significant impairment in functioning. Qualifiers are related to the age at onset (or unspecified age), limited emotions

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that would be considered pro-social, and mild, moderate, or severe condition. Oppositional defiant disorder is a common premorbid condition in younger children. The symptoms of conduct disorder happen between the age of 12-18 years of age with frequent rejection of pro-social peers, adopting associations with delinquent peers. The prevalence is around 4 percent, seen more commonly in boys than in girls. Risk factors include parental rejection/neglect, child abuse, sexual abuse, certain temperaments, and low verbal IQ states. Parents with conduct disorder or ADHD will have a greater likelihood of having a child with conduct disorder. Parental overindulgence can lead to the disorder as well. There is a great impact on functioning with this disorder, including educational deficits, STDs, unwanted pregnancies, and physical injuries from altercations or accidents. Parents are often deeply affected and blame themselves for their teen’s behavior. Family conflict is a big complication of this disorder. Things in the differential diagnosis include ADHD, oppositional defiant disorder, bipolar disorder, intermittent explosive disorder, adjustment disorder, and substance use disorder. ODD is seen in younger children when compared to conduct disorder, which is more commonly seen in older teens. ADHD will present with similar symptoms but they do not usually have malicious intent. Bipolar people do not usually have malicious intent. Patients with IED will have remorse after their outbursts. Adjustment disorders tend to fade over time after an identifiable stressor. While CD and substance use disorder are comorbid conditions, they are discrete entities.

ANTISOCIAL PERSONALITY DISORDER (301.7) Antisocial personality disorder or APD is a personality disorder when the patient habitually and pervasively violates and disregards the rights of others and who have no remorse in doing this. They can be recurrent criminals, may engage in criminal behavior, or engage in behaviors that skirt the edges of the law. They are considered to be amoral, unethical, and irresponsible, continually violating social norms and expectations. They make personal decisions based on

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their desires of the moment and do not consider the needs or the effect they are having on other individuals. These individuals are considered sociopaths or psychopaths. The person is not generally a loner or isolated socially as the name implies but is against rules, norms, laws, and societally-acceptable behavior. They can be attractive and charismatic, being very good at manipulating others, often gaining others’ sympathy and portraying themselves as the victim of social injustice. They tend to be bright and superficially charming; they are intuitive and know how to use this to manipulate others. They can harm others without feeling guilty or remorseful. Some will use empathy to derive pleasure out of another’s suffering but others are unempathetic. There are four major criteria for APD, which have some sub-features. Criterion A describes an individual who disregards and violates the rights of others since the age of fifteen to include lying or deception for profit or amusement, failure to obey laws, impulsive behavior, aggression and irritability, disregarding the safety of self or others, lack of remorse, and irresponsibility. Criterion B includes being at least 18 years of age. Criterion C includes having the symptoms prior to 15 years of age. Criterion D includes not being schizophrenic or bipolar. Individuals who are 15-18 years of age can have antisocial features but cannot actually have the disorder. In such cases, the individual would be diagnosed with conduct disorder. The prevalence of APD is about 0.02-3 percent. Risk factors include being male, having a firstdegree relative with the disorder, and possibly having certain neuroanatomical abnormalities. This can also be a developmental outcome for children who have conduct disorder, oppositional defiant disorder, or reactive attachment disorder. Comorbid states include other personality disorders and substance abuse disorders. There is no effective treatment for APD except for incarceration or legal supervision to contain their often-harmful behaviors. Those who have some degree of empathy can be trained to be more socially appropriate but this is uncommon. There are reports of some finding “religion” and reforming their behavior. Incarceration does not actually deter these people as they are unresponsive to punishment. They do not see themselves as part of society nor are they

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limited by societal rules. These individuals frequently “burn out” by 40 years of age as a result of physical ailments and emotional depletion.

PYROMANIA (312.33) This is a specific impulse control disorder involving difficulty in controlling one’s emotions and behaviors. They feel the need and compulsion to destroy the property of others through setting fires. They have the strong urge to watch fires or to set new fires, often endangering their own lives as a result. The main criterion is the deliberate and repeated setting of fires. There is increased tension before setting a fire and relief in starting and watching the fire. There is no monetary gain or other gain in setting a fire—only gratification and release of tension. Things like conduct disorder and other psychiatric illness must first be ruled out when making the diagnosis. The individual with pyromania spends a lot of time affiliated with fire departments and may become firefighters. When the fire is started, they will generally stick around to watch it being fought by firefighters. They will sometimes start small fires or set off false alarms to call the fire department to their location. This is seen much more often in males who have a learning disability or lack of social skills. There is an emotional connection to setting fires that they will describe as part of their pathology. The common comorbidities are alcohol use disorder, bipolar disorder, antisocial personality disorder, and depressive disorders. Pathological gambling is also a comorbid disorder. In fact, pyromania rarely is seen as a primary diagnosis. The mean age at onset is 18 years, with fires set about every six weeks (as an average). Many will also have mood disorders or other impulse-control disorders. The incidence is less than 1 percent in the general population. The actual diagnosis of pyromania in childhood is extremely rare, even though 40 percent of people arrested for arson are less than eight years of age. There is a distinction between fire setting in conduct disorder, ADHD, or other impulse control disorders and the setting of fires in pyromania. The research on pyromania is scant so the exact etiology of the disorder is

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unknown. The treatment of pyromania is often psychopharmacological, using SSRIs, opioid antagonists, mood stabilizers, and antipsychotic drugs. People with pyromania often have antisocial behavior, with antisocial behavior strongly predictive of recidivism in fire-starting behavior. Children who have an interest in fires and antisocial behavior need to be monitored and continuously treated in order to avoid developing pyromania-related behaviors. Patients with this disorder need lifelong contact with qualified psychiatric personnel to monitor their behavior long-term.

KLEPTOMANIA (312.32) This is a disruptive, impulse control, and conduct disorder because the individual is unable to regulate and control their emotions and behaviors. The individual is unable to resist the impulse to steal things. The objects that are stolen are not needed and have no monetary value. They have persistent urges to steal and cannot control the resultant behavior. There is intense relief of tension upon stealing something, which is the reason why they steal (and not secondary to conduct disorder or other mental illness). These people can refrain from stealing if there are cameras, security guards, or other deterrents and they are aware that their behavior is wrong. They feel guilty about their behavior and fear the consequences but it does not stop the behavior. Some will have remissions for long periods of time with only brief stealing episodes; others will have longer periods of stealing with brief remissions; still others will have continuous stealing behaviors. The individual seems to have some neurotransmitter pathways involved with stealing behaviors: namely the serotonin, dopamine, and opioid pathways. It is somewhat related to OCD and carries a high incidence of comorbid substance abuse. It is a rare disorder, seen in only 0.3-0.6 percent of the population with a 3:1 female to male ratio. It is usually first seen in adolescence but can be seen at any age less commonly. Comorbidities with kleptomania include bipolar disorder, eating disorders, anxiety disorders, substance use disorders, personality disorders, compulsive buying disorders, depression, and 220

other impulse-control disorders. Treatment involves cognitive behavioral therapy and a variety of psychopharmacological agents, such as lithium, anti-seizure drugs, and opioid antagonists. Antidepressants are used if there is a great deal of shame and depressive symptomatology around the behaviors. Naltrexone, in particular, has been found to be helpful. Certain subtypes of kleptomania are highly linked to obsessive-compulsive disorder. The prognosis of kleptomania mainly involves the legal consequences of their behavior. More than two-thirds are arrested at some point. About a third are not convicted but are arrested. Ten percent are convicted but haven’t been incarcerated. About 20 percent are incarcerated for their behavior. These individuals must remain in some type of therapy or treatment in order to monitor their impulses and behavior.

OTHER SPECIFIED DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDER (312.89) This is a catchall diagnosis for patients who will have some symptomatology consistent with a disruptive, impulse-control and conduct disorder but will not completely meet all of the criteria for any specific disorder. Individuals will either be out of the age range or will have an atypical presentation. The clinician can specify the diagnosis and list the features the patient has that qualify for this type of disorder.

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KEY TAKEAWAYS •

The category of disruptive, impulse-control, and conduct disorder is new to the DSM-V and encompasses disorders that used to be in other categories.

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Some of the disorders in this category are seen just in children, like oppositional defiant disorder and conduct disorder, while others are seen just in adults.

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Many of these disorders are comorbid with one another.

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Kleptomania and pyromania represent specific impulse-control disorders that relate only to certain behaviors that relieve the patient’s tension.

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QUIZ 1. Which disorder is specifically reserved for diagnosis in children and adolescents? a. Conduct disorder b. Oppositional defiant disorder c. Intermittent explosive disorder d. Pyromania Answer: b. Oppositional defiant disorder involves children who consistently defy authority, test limits, and misbehave when instructed to behave in a normal fashion. 2. What disease has the greatest risk of developing in untreated oppositional defiant disorder? a. Conduct disorder b. Kleptomania c. Bipolar disorder d. Intermittent explosive disorder Answer: a. A high-risk disorder that can come out of untreated oppositional defiant disorder is conduct disorder. 3. How frequently do the symptoms of intermittent explosive disorder need to happen in order to make the diagnosis, according to the DSM-V? a. Three times a week b. Twice a week c. Once a week d. Twice a month

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Answer: b. The symptoms of explosive behavior need to happen two times a week for the diagnosis of intermittent explosive disorder. 4. How long should the symptoms of intermittent explosive disorder happen in order to make the diagnosis of the disorder, according to the DSM-V? a. One month b. Three months c. Six months d. One year Answer: b. The diagnosis is made after symptoms of intermittent explosive disorder occur for a minimum of three months. 5. At what age is conduct disorder usually diagnosed? a. Age 5-12 b. Age 12-18 c. Age 18-25 d. Above age 25 Answer: b. The diagnosis is made only in those individuals under the age of eighteen years. It is basically synonymous with juvenile delinquency and is diagnosed between 12 and 18 years of age. 6. Which personality disorder is most closely linked to conduct disorder? a. Antisocial personality disorder b. Schizoid personality disorder c. Borderline personality disorder d. Narcissistic personality disorder

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Answer: a. The individual with conduct disorder can develop into antisocial personality disorder, particularly if it is not treated in adolescence. 7. What adjectives are least likely to be linked to a person with antisocial personality disorder? a. Superficially charming b. Unempathetic c. Social loners d. Manipulative Answer: c. These individuals can be identified as being cunning superficially charming, unempathetic, and manipulative but are far from being isolative or social loners. 8. According to the criteria for antisocial personality disorder, the individual must be how old before the diagnosis can be made? a. 15 years b. 18 years c. 21 years d. 25 years Answer: b. While the symptoms of APD must have started prior to 15 years of age, the diagnosis cannot be made until the individual is at least 18 years of age. 9. Criterion D in individuals who have antisocial personality disorder excludes the presence of which two disorders? a. Schizophrenia and bipolar disorder b. Substance use disorder and ADHD c. Anxiety disorder and conduct disorder d. Oppositional defiant disorder and narcissistic personality disorder

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Answer: a. Criterion D involves having symptoms that are uninvolved with having schizophrenia and bipolar disorder. 10. Patients with antisocial personality disorder may have a developmental outcome disorder secondary to a childhood disorder. Which would least likely be a childhood disorder leading to APD? a. Reactive attachment disorder b. Oppositional defiant disorder c. Autism spectrum disorder d. Conduct disorder Answer: c. Having any one of these childhood disorders can lead to antisocial personality disorder, except for autism spectrum disorder.

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CHAPTER FIFTEEN: SUBSTANCE ABUSE AND RELATED DISORDERS This chapter is about the DSM-V category of substance abuse and related disorders. It includes a variety of substances of abuse and their complications. Each has unique features that separate them it other substance abuse disorders and has different people at risk for the disorder. In addition, gambling disorder is included as a “related disorder” as it shares similar features to substance use disorders.

SUBSTANCE-RELATED DISORDERS There are eight recognized substance categories in the DSM-V that represent alcohol, caffeine, cannabis, hallucinogen, inhalant, sedative/hypnotic or anxiolytic, stimulant, and tobaccorelated disorders. There are dozens of specific disorders, starting with a “use disorder,” such as alcohol use disorder. There are also disorders related specifically to the withdrawal from the substance. There is a range of specified disorders linked to depression, bipolar disorder, anxiety disorders, neurocognitive disorders, psychoses, sleep disorders, and sexual dysfunction. Specific intoxication disorders are also given their own DSM-V diagnosis, making it challenging to find the right code.

ALCOHOL-RELATED DISORDERS There are a number of DSM-V-listed alcohol-related disorders. The two most common are alcohol use disorder and alcohol withdrawal. Alcohol use disorder involves both the abuse of alcohol and dependence on the substance. It is commonly referred to as alcoholism, affecting about 18 million people in the US. While use of the substance does not mean alcohol use disorder is present. It becomes AUD when the drinking behavior causes distress or harm to the 227

patient. Features of AUD include physical dependence, craving, and an increased tolerance for alcohol. The patient has nearly continual cravings for alcohol and will have withdrawal when they cannot get it. Dependence means the need to take increasing amounts of alcohol to have the same effect. There is a lack of control over drinking and inability to restrain the drinking behavior. There is a great deal of time spent on alcohol procurement, use, and withdrawal. This disorder is not curable but is treatable; there is a high rate of medical and psychiatric comorbidity with early mortality likely. People with alcohol use disorder are often negligent in other important areas of their life. They make poor choices under the influence of alcohol and may have legal or social consequences. This tends to be a family disorder in which recovery often depends on family members’ encouragement of the alcoholic to seek treatment and support of their recovery. The goal of treatment is to bring about complete abstinence. The recurrence rate after treatment (within one year) is about 35 percent. Things that aid the recovery include supportive friends and family, personal motivation to stay sober, and a lack of comorbidities. The three steps to recover include 1) detoxification (which may require medical supervision), 2) rehabilitation, and 3) sobriety maintenance. Withdrawal and detoxification often require benzodiazepines to manage symptoms. Those who reach the maintenance stage can be treated with several different drugs, including acamprosate, disulfiram, and naltrexone. If there are comorbidities like depression, these are treated with antidepressants or other drugs. Therapy involves cognitive behavioral therapy, behavioral intervention, and interactional group therapy like AA or another 12-step program. Alcohol withdrawal is a DSM-V diagnosis found in individuals who have alcohol abuse disorder or heavy use of alcohol and then stop or decrease the use. The period of drinking necessary to cause withdrawal can be weeks, months, or years of drinking. Higher alcohol use will increase the risk of withdrawal, which can be seen in adults, adolescents, or children who drink heavily and then stop. This is considered evidence of probable serious alcohol addiction. 228

Alcohol withdrawal symptoms can occur as soon as two hours after drinking cessation but usually happen about 8 hours after the last drink. The symptoms tend to peak at 24-72 hours after stopping alcohol. The symptoms include tremors, tachycardia, diaphoresis, agitation, anxiety, nausea/vomiting, seizures, and hallucinations (in severe cases). Other common symptoms in alcohol withdrawal are fatigue, depression, mood swings, confusion, nightmares, and irritability. The symptoms can escalate suddenly and may be life-threatening. Risk factors include consuming alcohol for a long period of time, having a history of delirium tremens, having intense alcohol cravings, and having been through detoxification in the past. These will predict a longer and more severe course of alcohol withdrawal. The symptoms as noted will cause intense distress and/or impairment in function. It can be misinterpreted, with other things in the differential diagnosis. Drug screening for other substances may need to be done to rule out intoxication from another substance. Encephalitis, meningitis, hypoglycemia, and delirium for other medical reasons should also be ruled out. Mental disorders like schizophrenia can mimic alcohol withdrawal. The goals of treatment are to keep symptoms to a low level and to prevent complications. This can be a medical emergency, with the main treatment being a long-acting benzodiazepine. A second-line treatment might be carbamazepine, which is less addicting. Antipsychotics might be necessary to reduce hallucinations and resultant agitation; Clonidine can be used for hypertension and beta blockers can be used for tachycardia. Phenytoin is used only if the person has an underlying seizure disorder.

CAFFEINE-RELATED DISORDERS Caffeine-related disorders include caffeine intoxication, caffeine abuse disorder, and caffeine withdrawal. With caffeine intoxication, there can be physical, psychomotor, and emotional/mental impairments after over-consumption. Most of the time, caffeine intake comes through coffee consumption but it can be seen in soda, energy drinks, analgesics, chocolate, tea, and cold medicine. The goals of taking are to improve cognitive function, alertness, concentration, and mood. It is consumed by 85 percent of adults in the US. 229

Intoxication is short-lived, but can be lethal. Symptoms of caffeine intoxication can include sleep loss (the most common symptom), nervousness, increased urination, stomach upset, hypertension, and irritability—usually when ingesting 250 mg or more of caffeine at one time. The DSM-V diagnosis is made after ingestion of 250 mg or more of caffeine and with five of these symptoms: nervousness, restlessness, insomnia, flushing, diuresis, GI upset, twitching, psychomotor agitation, cardiac arrhythmia, rambling speech, tachycardia, increased energy levels, and excitement. Risk factors for the disorder include being an infrequent user of caffeine. It can easily mimic the use of other substances, like nicotine and alcohol. Sleep disorders can mimic caffeine intoxication as can mania and hypomania. Anxiety can exacerbate caffeine intoxication and anxiety can be exacerbated by its use. Intoxication can impair motor skills in someone who requires high precision in the workplace. Young people who use energy drinks are at risk for intoxication as are body builders. Some people trying to lose weight can have caffeine intoxication. Severe caffeine intoxication can lead to a heart attack and death from overstimulation of the nervous system. Dialysis can be used to decrease the caffeine level as can diuretics. The effects of caffeine intoxication will wear off after a day or so. It is often treated simultaneously to treating caffeine addiction with the addition of some psychological therapy after the physical effects have worn off. The diagnosis of caffeine withdrawal is new to the DSM-V. This is because it may require psychological intervention. People who are trying to overcome caffeine addiction do so because a doctor has recommended it or because it is for health-related reasons. Treatment of withdrawal happens along with the treatment of addiction. It involves treatment facilities in some cases, along with psychotherapy and behavioral therapy. Withdrawal symptoms include irritability, anxiety, depression, fatigue, headache, and difficulty concentrating. Relapsing happens because the patient wants to relieve the symptoms. The most common symptom seen is headache, which happen within 12-24 hours of stopping 230

caffeine intake. Caffeine is sometimes used to self-medicate anxiety and depression; its use actually lowers the suicide risk. Stopping the drug often increases the risk of using other substances of abuse. Caffeine use disorder is not actually a DSM-V diagnosis but it has been labeled a condition that warrants further study. Caffeine is used daily by 80 percent or more of Americans without any distress or impairment in function. Remember that these are required for nearly every disorder in the DSM-V. Suggested symptoms for the disorder include ongoing desire to stop using caffeine, using caffeine despite obvious harm, and withdrawal symptoms. These are conservative criteria that haven’t fully been flushed out yet and there is concern over stigmatizing too many people who would otherwise qualify as having a mental illness. In addition, caffeine has positive effects in some situations. There does appear to be a genetic influence on the development of caffeine addiction. Caffeine addiction is commonly seen in identical twins, particularly with heavy users. The same is true of the development of withdrawal symptoms. About three percent of caffeine withdrawal patients have a dependence on another drug, such as heroin, cocaine, and marijuana. There is no specific treatment for withdrawal from caffeine as the symptoms are short-lived. If caffeine cessation is desired, it can be done gradually to reduce the symptoms of going off the substance.

CANNABIS-RELATED DISORDERS The main DSM-V diagnosis related to cannabis use is cannabis or THC intoxication. Cannabis is the most widely used illicit drug in the world (and in the US). It has been legalized in many states, can be smoked, eaten, or drank in a tea. THC binds to cannabinoid receptors in the brain, interfering with brain function. There are acute and chronic effects in cannabis intoxication. These include sleepiness, increased hunger, disorientation, impaired cognition, and acute psychosis. Physical symptoms of intoxication include dry mouth, red eyes, tachycardia, and increased appetite within two

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hours after using marijuana or other form of cannabis. Increased hunger is unique to cannabis intoxication versus other kinds of intoxication. With intoxication, there is a brief period of euphoria and short-term memory deficits. Then there is lethargy, sleepiness, and impaired judgment. Patients may have anxiety and social withdrawal. Hunger is often present, along with the other physical symptoms. The onset of intoxication is within five minutes of smoking but a few hours if taken by mouth. The effects last 3-4 hours when smoked. Testing for THC intoxication should happen with blood testing as the urine testing will be delayed. It takes 3-10 minutes for it to be elevated in the blood. The acute phase of marijuana intoxication will resolve within 4-6 hours. The patient simply needs support, decreased stimulation and calming. Benzodiazepines are used for the treatment of anxiety related to cannabis intoxication. Even without treatment, the anxiety will pass within a few hours. Lorazepam is a drug of choice in treating anxiety related to cannabis intoxication. Most patients do not need acute hospitalization. There is a condition called cannabis-induce anxiety disorder that will resolve when cannabis is no longer used. Cannabisinduced sleep disorder can also develop as a result of intoxication, which can last up to a month. The DSM-V also recognizes cannabis use disorder. Cannabis produces reward, dependence, and withdrawal symptoms. Regular use of cannabis can result in varying degrees of impairment. The criteria for cannabis use disorder involve the following: •

Use of cannabis for a minimum of one year

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Increasing use of the drug

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Repeated failures to decrease the use of the drug

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Excess time is spent procuring, using, or recovering from the drug

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Cravings for cannabis use

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Continued use despite adverse consequences

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Neglect of other life activities by using cannabis

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Driving while on cannabis

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Continued use despite physical or psychological problems attribute to its use

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Tolerance to cannabis

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Withdrawal symptoms when not using cannabis

There are specifiers, which include being in a controlled environment, and three degrees of severity. Risk factors include conduct or antisocial personality disorder. Low socioeconomic status, tobacco abuse, unstable family life, low academic performance, and having family members who smoke are other risk factors for the disorder. The disorder usually starts in adolescence or young adulthood. Things in the differential include depression, which has similar symptoms. There are also a number of comorbidities. Most of these are physical and include COPD and respiratory difficulties, heart disease, reproductive system disturbances, and an increased risk of lung, esophageal, and oral cancers. Cannabis use disorder is treated with individual or group therapy that involves psychoeducation about the effects of cannabis as well as self-help groups and lifestyle alterations. Twelve-step groups can help in the recovery from this use disorder as it is for other drug use disorders. Cannabis use generally declines with age as people develop other coping skills and responsibilities. Long term use is linked to lack of motivation. A few individuals will have chronic lifelong, heavy use. They will have an insidious downhill course in life. The prognosis is excellent with treatment.

HALLUCINOGEN-RELATED DISORDERS The main hallucinogen-related disorder is hallucinogen persisting perception disorder (previously known as post hallucinogen perception disorder). This is a condition in which an individual, after discontinuing hallucinogens, will still have ongoing simple visual hallucinations. 233

It happens after a prolonged period of taking psychedelic drugs and is considered a “flashback disorder.” The person will have frequent flashbacks that may be mild, moderate, or severe. Symptoms include regular visualizations of colors, halos, or other visual disturbances. Colors will change over time with difficulty recognizing the intensity of a certain color. Flashes of bright light can be seen that will come and go. They will often see after-images after staring at an object for a long period. Reading can be interfered with because of the visual disturbances. False images are seen as well with faces or geometric patterns seen. Objects will be seen as dynamic instead of static and haloes around objects can be seen. The prevalence of this disorder among drug users is about 4 percent. It can last for weeks, months, or years after prolonged hallucinogen use. It is seen mostly with LSD and mushroom use. It can happen after the first use of a hallucinogen (this is believed to be a genetic predisposition). In most cases, it happens after prolonged drug use. Neuroimaging studies will be negative and there is no available treatment, including drug therapy.

INHALANT-RELATED DISORDERS This mainly involves “inhalant use disorder” in which the patient regularly inhales hydrocarbonbased fumes, such as those found in solvents or paints, for the purpose of altering the patient’s mental state. It leads to significant impairment in the user’s life. While these are not technically addictive, the patient will have a strong desire or craving to use these substances and will use increasing amounts of the substances, despite wanting to cut down or stop the behaviors. The major effects of the use include slurred speech, impaired motor coordination, nystagmus, tremors, and blurry vision. The individual seeks out the euphoria seen with the use of the substance to the exclusion of personal obligations. Brain changes can be seen on an MRI of the brain and the patient can develop rhabdomyolysis from the use of inhalants, which can lead to renal failure. There can also be a peri-oral or perinasal rash. Users are typically adolescents and young people who do not have access to other drugs or alcohol. About 0.4 percent of teens aged 12-17 will meet the criteria for this disorder,

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with 10 percent of teens using inhalants at least once. It is often seen with other substance use disorders, conduct disorder, antisocial personality disorder (in adults), depression, and suicidality. There is an increased risk of nicotine, alcohol, cocaine, amphetamine, and hallucinogen use in adults, as well as personality, anxiety, and mood disorders. There are no medications that are helpful in treating inhalant abuse. The patient can be treated with typical substance abuse treatment strategies as well as psychotherapy. Many will have comorbidities that may be treated with medications and/or therapy. Inpatient or outpatient treatment strategies can be used. Patients with severe comorbidities often are more motivated to quit inhalant use. Because of their comorbidities, many will require lifetime psychiatric or psychological support.

SEDATIVE-, HYPNOTIC-, OR ANXIOLYTIC-RELATED DISORDERS Since ancient times, self-medication for insomnia and anxiety has taken place. A combination of alcohol and opium was initially used, with other drugs used in the 19th century. Barbiturates and benzodiazepines became popularized in the 20th century. The use of sedative-hypnotics and benzodiazepines continues to this day. Both substance abuse and substance dependence on these drugs exist. Abuse implies use that is harmful to the individual and dependence implies the need to use the drug to function normally. These can happen together or separately. The new DSM-V has combined the abuse and dependence on these types of drugs into one substance use disorder, in which there needs to be distress or functional impairment when using the drug. Drug craving is one of the symptoms but it is not a requirement. Legal problems have been removed as a symptom. Some will use these drugs to self-medicate, while others are using it for euphoria and other positive symptoms. Use for a minimum one month is necessary for drug dependence to occur. Use of the drug can cause drowsiness, impaired judgment, and motor impairment. Anterograde amnesia is a typical complication of using benzodiazepines or sedative-hypnotics.

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Complications tend to occur when the patient is using some other type of drug along with benzodiazepines or sedative-hypnotics. Barbiturates on their own will cause stupor, coma, and respiratory depression—even in small doses. Withdrawal can cause hallucinations, seizures, anxiety, insomnia, tremor, autonomic symptoms, and psychomotor agitation. Reemergence of an anxiety or mood disorder can happen and does not usually subside. Withdrawal is seen after four months or more of use. Even with therapeutic doses, there can be prolonged insomnia, irritability, and anxiety after stopping the drug. The diagnosis requires two of these criteria to be met: •

Continued use of the drug despite negative personal consequences.

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Impaired functioning in one or more life areas.

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Use in hazardous situations.

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Continued use despite social or interpersonal issues when taking it.

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Tolerance to the drug.

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Withdrawal symptoms when stopping the drug.

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Unsuccessful attempts to stop drug use.

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Spend time procuring, using, or recovering from the drug.

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Avoiding activities in order to use.

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Persistent cravings for the drug.

Flumazenil can be used for overdose or intoxication but it can cause seizures and severe withdrawal symptoms. Benzodiazepine use alone probably does not need reversal as it can be treated supportively and does not result in death. Barbiturate overdoses can be treated with urine alkalization or dialysis. Phenobarbital tapering will also help an overdose/dependence situation. Withdrawal can be prevented by tapering doses of phenobarbital as well. Melatonin and zolpidem will reduce the insomnia seen after stopping these drugs. Cognitive behavioral therapy and twelve-step programs can help with treating the addiction.

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STIMULANT-RELATED DISORDERS Stimulants include methamphetamine, amphetamines, and cocaine. They will increase the patient’s energy levels, levels of alertness, and attention. They will increase the heart rate and respiratory rate. They can be used in the management of narcolepsy, ADHD, depression, and obesity. The stimulant disorders include stimulant intoxication, stimulant use disorder, and stimulant withdrawal. Stimulant intoxication is the diagnosis when there has been recent stimulant use. There will be hypervigilance, euphoria, interpersonal sensitivity, anger, auditory hallucinations, repetitive movements, and paranoid thoughts. Fast or slow heartbeat can be seen, as will changes in blood pressure, sweating or chills, nausea or vomiting, muscle weakness, and weight loss. Chronic high dose use will lead to prolonged sadness, decreased blood pressure, and decreased heart rate. Stimulant use disorder requires a 12-month period of time when the person is abusing the drug to the detriment of their health and psychosocial situation. Withdrawal symptoms include tiredness, insomnia, hypersomnia, slow heartbeat, and vivid or unpleasant dreams. They can occur within hours to days of stopping the drug. Anhedonia is a prominent feature of stopping the drug.

TOBACCO-RELATED DISORDERS Tobacco use disorder involves an addiction to nicotine, the psychoactive component of tobacco products. Nicotine is a CNS stimulant, which can lead to appetite suppression, improved concentration, enhanced memory, hyperglycemia, increased respiratory rate, hypertension, and tachycardia. It can be inhaled, snuffed or chewed. The half-life of nicotine is two hours so the smoker often smokes every two hours. Withdrawal happens with in an hour after the last dose with symptoms of cravings, anxiety, irritability, and annoyance. Tobacco companies have added ammonia to cigarettes to enhance nicotine absorption and bioavailability.

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There are three main criteria for tobacco use disorder with fifteen sub-features and four specifiers, according to the DSM-V. The three criteria include consuming larger quantities of tobacco for a longer period than intended, tolerance for nicotine, and withdrawal symptoms when ceasing tobacco use. The specifiers include early remission (no use for 3-13 months), no use for greater than 12 months, or on transdermal nicotine or other maintenance therapy. There are also specifiers for mild, moderate, or severe disease. The DSM-V indicates that twenty percent of those aged 18 will use tobacco products at least monthly. Many of these teens will become daily smokers. Cigarettes make up more than 90 percent of tobacco use. About 21 percent of individuals are current smokers, while 22 percent are former smokers. Smokeless tobacco use (chewing tobacco and snuff) makes up less than five percent of users. Pipes and cigars make up less than 1 percent of individuals. Risk factors for tobacco use include low income levels, low level of education and having several other psychiatric disorders, including ADHD, conduct disorder, depression, personality disorders, and other substance use disorders. These are frequent comorbidities, particularly other substance use disorders. Treatment for tobacco use disorder involves social support with self-help groups, exercise, cognitive behavioral therapy, nicotine replacement therapy, and pharmacological interventions, such as Zyban and Chantix. There are serious consequences of not quitting, including coronary artery disease, lung cancer, oral cancer, esophageal cancer, and COPD. Tobacco withdrawal is another DSM-V disorder that has been reclassified, formerly known as nicotine withdrawal. It involves several symptoms that come directly from stopping the use of tobacco. Typical symptoms of withdrawal include restlessness, poor concentration, irritability, depression, increased appetite, insomnia, and cravings, which can last weeks to years. The symptoms are worse in the first week after quitting smoking.

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NON-SUBSTANCE-RELATED DISORDERS This currently involves just gambling disorder. It is a non-substance-related disorder that has been placed in this category because of the clinical similarities between gambling and substance use.

GAMBLING DISORDER (312.31) Gambling is considered a potential behavioral addiction as listed by the DSM-V. The concept of dependence is increasingly being applied to things like gambling, exercise, shopping, sex, electronic media use, and eating. Currently gambling is the only behavioral addiction applied to the DSM-V but others are being considered, including internet gaming addiction. Gambling used to be an impulse control disorder but its neurological basis leads to commonalities with drug addiction. Gambling is defined as risking money or valued items/behaviors in the hope of getting something of greater value. Most people can do this without qualifying as having a behavioral addiction. They play with the expectation of losing and do not get upset at the loss, often using disposable income to play or playing with money they have already won. People with a gambling addiction will gamble with money allocated for living expenses or will get themselves in debt in order to gamble. They will sell valuable items to get money to gamble with and will be shocked, outraged, or angry if they lose. Their excitement at winning is in excess of what others experience when gambling and may even stake behaviors on the outcome (such as trading sex for money to gamble with). There will be superstitious thinking, magical thinking, and distortions of reality associated with the gambling process. The goal of the gambler is short-term reward and not the long-term consequences. They cannot delay gratification and are believed to be chronically dopamine deficient. Personality characteristics of the gambler include impulsive, susceptible to boredom, restless, competitive, lonely, and depressed.

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The main symptoms of gambling disorder include increased tolerance (the need to gamble more money to get the same effect), withdrawal symptoms (restless and irritable), unsuccessful attempts to stop or cut back, self-soothing with gambling (which “medicates” mood), chasing losses with further gambling, shame, consequences in daily life, depletion of assets, and lack of mania as a primary diagnosis. There are several specifiers, including episodic gambling, persistent gambling, in early or sustained remission, and mildly, moderately, or severely affected by gambling addiction. Risk factors include certain temperamental factors that lead to childhood gambling behaviors, physiological factors, and genetic factors. There is no evidence to support a true low dopamine level nor is there evidence of dopamine increases with gambling or winning at gambling. The onset can begin in adolescence up to late adulthood. Women have a faster progression than men with the disorder. The differential diagnoses include non-pathological gambling, manic phase of bipolar disorder, and antisocial personality disorder. There are many comorbidities with gambling disorder, including many types of health problems, substance use disorders, depressive disorders, anxiety disorder, and antisocial personality disorder (or other personality disorders). It can be treated with self-help or peer support groups, cognitive behavioral therapy, and certain drug interventions, such as SSRIs. The problem tends to resolve at some point but it can take many years of losses and adverse consequences.

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KEY TAKEAWAYS •

Substance and related disorders include a wide variety of addictive and nonaddictive drugs plus gambling addiction.

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Hallucinogen use can cause persistence of perceptual difficulties but these drugs are generally not addictive.

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Inhalants are not addictive; however, individuals can be addicted to the feelings they get from using these substances.

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Most other drugs of abuse have an addictive potential.

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Gambling addiction involves a behavioral addiction that is believed to have a neurological basis.

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QUIZ 1. The need to take increasing amounts of a substance in order to have the same effect is called what? a. Craving b. Abuse c. Tolerance d. Dependence Answer: c. The need to take increasing amounts of a substance in order to have the same effect is referred to as “tolerance.” 2. Which is not a step which happens in alcohol abuse disorder recovery? a. Addiction b. Detoxification c. Rehabilitation d. Sobriety maintenance Answer: a. There are three steps to alcohol abuse disorder recovery; these do not include addiction, which is part of the disorder and not the recovery process. 3. Which is not a drug used for maintenance in the management of alcohol abuse disorder? a. Acamprosate b. Naltrexone c. Disulfiram d. Librium Answer: d. Librium is used for acute withdrawal but is not used in maintenance management of alcohol abuse disorder.

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4. What is the main symptom seen in caffeine withdrawal? a. Insomnia b. Irritability c. Depression d. Headache Answer: d. The main symptom seen in caffeine withdrawal is a headache, seen within 12 hours of stopping caffeine use. 5. What unique feature of cannabis intoxication isn’t seen with other illicit drug intoxications? a. Hallucinations b. Dry mouth c. Increased hunger d. Perceptual distortion Answer: c. Increased hunger is unique to cannabis intoxication and isn’t seen when other drugs of abuse are used in intoxicating circumstances. 6. The patient is suspected of having an acute cannabis intoxication. What test will most commonly show the diagnosis? a. Hair analysis b. Blood analysis c. Urinalysis d. Saliva testing Answer: b. The blood testing will be positive within a few minutes after taking the drug, making it the best test for detecting an acute intoxication.

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7. What is not considered a symptom of hallucination persisting perception disorder? a. Auditory hallucinations b. Haloes around objects c. Colors appear to change d. Afterimages Answer: a. The perception disorder involves visual disturbances seen after prolonged hallucinogen use. Auditory perceptual difficulties are usually not seen. 8. Which is not a feature of inhalant intoxication? a. Blurry vision b. Dry mouth c. Tremors d. Nystagmus Answer: b. Each of these is a feature of inhalant intoxication except dry mouth, which tends not to be seen with the use of inhalants. 9. What percent of teens have used inhalants at least once? a. 3 percent b. 10 percent c. 30 percent d. 50 percent Answer: b. About ten percent of teens have used inhalants at least once in the past.

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10. Which behavioral addiction is listed under addictive disorders in the DSM-V? a. Sex addiction b. Internet gaming addiction c. Eating addiction d. Gambling addiction Answer: d. While all of these are being considered as behavioral addictions, only gambling addiction is listed in the DSM-V as a true, neurological behavioral addiction.

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CHAPTER SIXTEEN: NEUROCOGNITIVE DISORDERS This chapter covers neurocognitive disorders, such as delirium and dementia. Both of these can cause mild, moderate, or severe cognitive deficits, which can be transient (as in delirium) or lifelong (as in most types of dementia). The DSM-V recognizes that there are major and mild neurocognitive disorders. There are different diagnoses for major or mild neurocognitive disorders with multiple different etiologies listed by the DSM-V.

DELIRIUM (293.0) Delirium is recognized by the DSM-V as a neurocognitive disorder in which the patient is having fluctuations in confusion and disorientation over a short period of time. There will be various degrees of consciousness, perception, cognitive disturbance, and attention deficits. The two main features under the DSM-V are changes in attention and cognition. Illusions and hallucinations are also main features. The patient is easily distractible and often cannot comprehend what is going on. The onset is fast, within hours to days. There will be sleep disturbances and behavior that is harmful to themselves or others. The symptoms of inattention and cognitive impairments can be seen in other disorders, such as autism spectrum disorder, ADHD, and schizophrenia. In delirium, these features are more serious; common sufferers are the elderly, those with dementia, and those suffering from drug intoxication or withdrawal. The DSM lists these criteria: A. Attention disturbance (lack of focus) and decreased awareness B. Quick onset of symptoms that tend to fluctuate C. Cognitive deficit D. Absence of coma or evolving dementia

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E. Evidence of physiological insult, substance intoxication, substance withdrawal, or toxic exposure F. Specifier that involves hyperactive or hypoactive level of activity or mixed level of activity There is a strong association with delirium and either mental disorders, neurological disorders, medical conditions, or substance/medication use. People with alcohol withdrawal or other drug withdrawal are treated with benzodiazepines, which can actually trigger delirium in some patients. There is a higher incidence of delirium with the elderly or those with underlying Alzheimer’s disease, Parkinson’s disease, or Huntington’s disease. The incidence of delirium is just 1-2 percent in the general population; 14-24 percent in hospitalized patients; and 70-80 percent in intensive care patients. About 83 percent of patients near the end of their life will have delirium. Of people with delirium secondary to a medical condition (versus a substance-related delirium), about 40 percent die within the next year (according to the DSM-V). Poor health and low functioning are positively associated with the presence of delirium. The hallucinations and delusions of delirium must be differentiated from that seen in bipolar disorder, depression, and psychotic disorders. Anxiety and dissociation seen in delirium also can be seen in acute stress disorder. The treatment of delirium is mostly medical and antipsychotics are most commonly prescribed. The diagnostic code for delirium according to the DSM-V must include the probable underlying cause for the delirium. Untreated, it can increase the risk of infections, respiratory failure, and death. There is always a risk of over-sedation in the treatment of delirium but this needs to be weighed against the aggressiveness of the symptoms. Risperidone along with light therapy will improve sleep time and will decrease delirium scores. Exercise and cognitive stimulation will also improve attention; these can be used along with drug therapy for the management of delirium symptoms.

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MAJOR NEUROCOGNITIVE DISORDER (294.X) This is a broad category involving several different diseases all associated with a severe cognitive impairment. Traumatic brain injuries and several types of dementia will have cognitive deficits that meet the criteria for major neurocognitive disorder; these are different from having an intellectual disability or pervasive developmental disorder. To make the diagnosis, there has to be significant cognitive decline from previous levels of performance in at least one area of cognition. These include language comprehension, language production, perceptual-motor skills, learning abilities, memory retention, executive functioning, and attention span. The patient can detect this themselves but it is often noticed by clinicians or caretakers. The patient cannot manage medications, pay bills, maintain hygiene, or maintain nutrition. Delirium needs to be excluded. Early indicators of a major neurocognitive disorder include sudden depressive symptoms, bipolar-like mood swings, agitation, disinhibition, anxiety, or apathy. Other things commonly seen are hypersomnia, insomnia, and circadian rhythm disorders. The diagnosis can be made using the MMSE (mini mental status examination), the Global Assessment of Functioning (GAF) scale, or other neuropsychological testing. The St. Louis University Mental Status assessment or SLUMS may also detect early cognitive decline, and may be more sensitive than any of the other tests. Women are at a higher risk for developing dementia and individuals who have jobs that require complex cognitive tasks will be detected earlier than most other people. Major neurocognitive disorder can be secondary to many different neurological diseases as well as traumatic brain injury. Patients with degenerative neurological diseases (such as Alzheimer’s disease, Lewy boy disease, Parkinson’s disease, prion disease, Huntington’s disease, etc.) are often diagnosed with mild or “minor” neurocognitive disorder first and then progress to major neurocognitive disorder. Traumatic brain injury and stroke can immediately lead to major neurocognitive disorder.

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Individuals with mood disorders, bipolar disorder, or schizophrenia spectrum disorders with severe psychosis have a higher likelihood of developing a neurocognitive disorder. The severity of depressive symptoms is also predictive of neurocognitive decline and major neurocognitive disorder. Having a life-threating illness will also predict the future development of a major neurocognitive disorder. HIV disease is also predictive of major neurocognitive disorder so that there is a separate diagnosis for neurocognitive disorder secondary to HIV. The prevalence of major cognitive disorder is difficult to know as there are many different etiologies. The prevalence is about 1-2 percent in those over 65 years but it is 30 percent in those 85 years or older. There are no actual treatments for major neurocognitive disorder; however, comorbid diseases can be treated. The type of neurocognitive disorder determines which treatment strategy is employed. Most people do not recover from this type of disorder and tend to gradually decline in function over time.

MILD NEUROCOGNITIVE DISORDER (331.83) Patients with mild neurocognitive disorder will present with a decline in cognitive functioning to include memory impairment, decreased ability to perform ADLs, and difficulty with language, social skills, and/or perceptual-motor skills. Mood disturbances are often seen as early findings, some of which may rise to the level of another psychiatric disorder. Like major neurocognitive disorders, the GAF scale, the MMSE, and the SLUMS assessment are used to diagnose the presence of early cognitive decline in mild neurocognitive disorder. It is important to remember that both major and minor neurocognitive disorders are secondary diagnoses so that there will always be a primary diagnosis to explain the neurocognitive deficit, except in cases of unspecified neurocognitive disorder and neurocognitive disorder due to multiple etiologies. It is a good idea to make the diagnosis when the patient has mild neurocognitive disorder so that, if any interventions can take place, they can take place before the disease can worsen.

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Treatment is based on the primary underlying cause. There are treatments for mild Alzheimer’s disease, for Parkinson’s disease, and to reduce the viral load in patients who have HIV disease. Each of these has the potential to manage mild neurocognitive disorder and to prevent it from becoming severe. Metabolic agents that enhance ATP, the primary molecule used for cellular energy, have the potential to slow or prevent further cognitive decline in patients with mild deficits. More research is necessary to determine if these agents will be helpful.

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO ALZHEIMER’S DISEASE As mentioned, major or minor neurocognitive disorder is generally secondary to another disorder. The most common disorder underlying neurocognitive disorders is Alzheimer’s disease or AD. Patients will have the incursion of neurofibrillary tangles and beta amyloid plaques in the brain, leading to progressive cognitive decline. Acetylcholine production of the nearby neurons decreases, which affects memory and behavior. There are three criteria for this disorder, including the following: A. The patient must meet the criteria for major or minor neurocognitive disorder B. The decline must be slow and insidious with ongoing cognitive deficits that worsen over years rather than months C. The patient must have “probable” or “possible” Alzheimer’s disease because of the genetic mutation being detected, the presence of steady cognitive decline, prominence of memory impairment, and a lack of other probable cause found. There are specifiers that indicate probable or possible disease, depending on which criteria are met (or not met). The onset occurs as “early onset” disease in the 50s and 60s, although it can occur as late as the 90s with late onset disease. The prevalence increases with age so that 25 percent of people aged 80 or older have this disorder. Risk factors for Alzheimer’s disease include having a traumatic brain injury and old age. Disrupted sleep is an early marker for Alzheimer’s disease. The strongest predictor for Alzheimer’s disease is daytime sleepiness. A common comorbidity is Down syndrome with 75 251

percent comorbidity in Down syndrome patients over 65 years of age. The differential diagnoses include thyroid disease (hypothyroidism), major depression, and any of the other causes of degenerative brain diseases and dementias. Polypharmacy can also cause cognitive impairment that will mimic Alzheimer’s disease.

MAJOR OR MILD FRONTOTEMPORAL NEUROCOGNITIVE DISORDER WITH FRONTOTEMPORAL DISEASE There are actually six frontotemporal dementias (FTDs) involving either the frontal or temporal lobes. These include behavioral variant of FTD, semantic variant primary progressive aphasia, non-fluent agrammatic variant primary progressive aphasia, corticobasal syndrome, progressive supranuclear palsy, and FTD associated with motor neuron disease. The disease was previously called Pick’s disease and only one type is now referred to as Pick disease. It is the second most common type of dementia in the US and accounts for 20 percent of young-onset dementia cases, causing symptoms between 45 and 65 years of age in both men and women. The major feature is social and personal behavioral changes, emotional apathy, and language deficits. There is no cure but there are treatments that may alleviate some of the symptoms. It is a heterogeneous disease with three major symptom classifications. These include the following: A. Behavioral variant FTD with social behavioral and conduct changes B. Semantic dementia, which is the loss of word comprehension with fluent speech C. Progressive nonfluent aphasia, which involves changes in speech production Things that tend to be preserved in FTD patients are memory, motor task abilities, spatial skills, and perception. Binge eating and compulsive behaviors are a major feature of FTD with prominence of abnormal eating preferences and behaviors. There is difficulty with executive functioning and working memory.

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MAJOR OR MILD NEUROCOGNITIVE DISORDER WITH LEWY BODIES Lewy body dementia or LBD includes both Parkinson’s disease and dementia with Lewy bodies (DLB), two dementias characterized by the development of abnormal deposits of alphasynuclein (a protein) in the brain. These are collectively known as synucleinopathies. REM sleep behavior disorder is a major component of this disorder, in which people act out their dreams. Patients will have visual hallucinations, slowness of movement, rigidity, difficulty walking, and fluctuations in attention. There will be blood pressure changes, heart and GI changes, and constipation. Mood changes like depression and apathy are often seen. The REM sleep disorder can appear decades before the dementia shows up (as many as 50 years before the dementia).

MAJOR OR MILD VASCULAR NEUROCOGNITIVE DISORDER This is also referred to as vascular dementia or multi-infarct dementia, caused by a series of minor strokes. These cause a stepwise decrease in cognitive functioning. There must be a temporal relationship between a stroke or more than one stroke and cognitive deficits in order to make the diagnosis. It should be noted that Alzheimer’s dementia often coexists with vascular dementia. The key is stepwise cognitive impairment with occasional improvements between events. The changes occur over 5-10 years. Signs are similar to other dementias except that there may be focal neurological signs, depending on the location of the stroke. There will be variable deficits in cognitive functioning. Severely affected patients may have dysarthria or aphasia if the language centers are affected. Frontal lobe deficits with behavioral issues and incontinence are more common in this type of dementia.

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MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO TRAUMATIC BRAIN INJURY There have been extensive changes in the DSM-V classification of various disorders, including dementia, amnesia, and delirium. Because of the stigma of the diagnosis of “dementia,” there have been different ways of describing these types of symptoms. The new addition includes aspects of visual spatial perception, social abilities, language, executive ability, learning and memory, and complex attention—deficits in any of these can cause functional impairment in brain injured patients and others with neurocognitive disorders. TBI (traumatic brain injury) is often seen in children under four years of age, adolescents (15-19 years of age), and adults over 65 years of age. More severe disease involves the phenomenon of abulia, which is lack of motivation, such that the patient is awake but doesn’t respond. Others will simply lack motivation and initiative, with psychomotor retardation and decreased emotional responsiveness. Some patients will perseverate and will be distractible so that it is difficult to maintain a conversation. The diagnosis of “post-concussion syndrome” is now called “minor neurocognitive disorder secondary to traumatic brain injury,” occurring in about 500 out of 100,000 individuals. It affects about 15 percent of head injured individuals after one year following their head injury. The most common complaint is headache, followed by dizziness. Other symptoms include blurry vision, diplopia, hearing loss, tinnitus, photophobia, and phonophobia. The diagnosis of major neurocognitive disorder secondary to traumatic brain injury involves a significant decline in baseline level of performance in one or more cognitive domains. It can be diagnosed from a standardized neuropsychological test, knowledgeable observer, or by clinical evaluation. The patient must have impairment in their level of independence. Delirium or other mental illness must be ruled out. Minor cognitive disorder tends not to interfere with independence but must affect one or more cognitive domains.

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SUBSTANCE/MEDICATION-INDUCED MAJOR OR MILD NEUROCOGNITIVE DISORDER This involves neurocognitive changes that can happen during an acute drug intoxication, during withdrawal, or as a late effect after taking a drug. It can involve a slow recovery of brain function after using a drug or other substance for a long time. In some cases, it can take months or years after stopping drug use in order to function in a completely normal capacity. Ongoing problems may always exist. Minor neurocognitive disorder involves everyday independence but requiring certain compensatory strategies in order to accomplish daily tasks. Drugs that can affect neurocognition include alcohol, which will last for 1-2 months after drinking cessation. It is more likely to occur in individuals older than 50 years of age. After using inhalant drugs, it may take years before the cognition returns to normal, especially people who inhale leaded gasoline. Cocaine can have lasting neurocognitive effects, particularly in older users. The same is true of methamphetamine abusers, particularly in those who also abuse ketamine. Opioid users will have neurocognitive problems after quitting, particularly regarding learning and memory. PCP users will also have persistent neurocognitive deficits. About one-third of those using sedative/hypnotics and benzodiazepines will have problems after stopping the drugs.

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO HIV INFECTION HIV not only affects the immune system, it also has major effects on the CNS. HIV disease is not as life-threatening as it once was but is now considered a chronic disease, with a normal lifespan expected. Combined antiretroviral treatment (CART) does not completely eliminate HIVrelated dementia, particularly milder forms of the disease. It can affect memory, attention, decision-making, learning, and problem-solving. Up to 50 percent of HIV-infected patients will be diagnosed with a mild neurocognitive disorder—at least partially. About 25 percent will fully meet the criteria and five percent will have major neurocognitive disorder from HIV disease. This is seen in young people in developing countries, where HIV treatments ae less available. 255

The diagnosis is made by meeting the requirements for a neurocognitive disorder with the addition of having confirmed HIV disease. The reason for the NCD must also not be from meningitis or progressive multifocal leukoencephalopathy. The major feature is struggling to complete simple tasks without significant concentration. Severe immunosuppression with a high viral load in the CNS is associated with NCD from HIV disease. Some may have ataxia, balance problems, and difficulty with coordination. Emotional control is difficult and there will be apathy in these patients.

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO PRION DISEASE The major prion-related neurocognitive disorder is Creutzfeldt-Jakob disease or CJD. This is always fatal and includes memory problems, behavioral changes, visual disturbances, and poor coordination of rapid onset so that most patients die within a year of the diagnosis. Prions are infectious proteins that cause misfolding of proteins. Most cases are sporadic and infectious with 7.5 percent inherited as an autosomal dominant disease. It is spread through contact with infected brain matter rather than through casual contact or blood transfusion. There is no treatment for the disorder except for supportive measures. The onset of the disorder is around sixty years of age. This is different from mad cow disease and variant Creutzfeldt-Jakob disease. The key finding is rapidly progressive dementia with memory impairment, personality changes, and hallucinations. About 90 percent of patients will have myoclonus as well. Frank psychosis is not uncommon. Gait and posture abnormalities as well as ataxia can be seen. An EEG will be diagnostic of the disease. Death can happen within weeks but usually happens within six months of the diagnosis. A small percent will live 1-2 years after their diagnosis.

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO PARKINSON’S DISEASE This is highly related to dementia with Lewy bodies and is a type of Lewy body dementia because of the finding of Lewy bodies in the brain of those with the disorder. The disorder starts as a movement disorder but progresses to include changes in mood and behavior 256

suggestive of dementia. About 78 percent of individuals with Parkinson’s disease will have dementia. There are fewer delusions than are seen in dementia with Lewy bodies and fewer hallucinations. Tremor at rest is a common feature. The diagnosis can only be proven after death with an autopsy of the brain. The diagnosis is made exactly the same way as dementia with Lewy bodies. It is called Parkinson’s dementia only if there is established Parkinson’s disease prior to the development of dementia. The onset of dementia must be about one year or more after the diagnosis of Parkinson’s disease.

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO HUNTINGTON’S DISEASE This is an autosomal dominant disorder that is uniformly fatal. There are blood tests that can identify who has the disease and who doesn’t. Early detection of the disease will enhance quality of life. The patient will gradually lose cognitive function and may or may not have behavioral disturbances. Both mild and major neurocognitive disorders can be seen as part of this disorder. Learning and memory are relatively unaffected. The disease diagnosis is made around 40 years of age but there can be early cognitive and behavioral abnormalities seen much earlier. Early symptoms include anxiety, depression, impulsivity, irritability, and apathy. Physical symptoms include difficulty with motor skills and fidgeting, which progress to choreiform movements and speech/swallowing abnormalities. The blood test and an MRI of the brain can be used to diagnose the disorder. The disease is gradually progressive with death occurring about 15 years after motor symptoms manifest.

MAJOR OR MILD NEUROCOGNITIVE DISORDER DUE TO MULTIPLE ETIOLOGIES In diagnosing this disorder, the first thing that must be established is that the patient has a mild or moderate neurocognitive disorder. This has already been discussed. After the diagnosis is made, a search for the etiology is undertaken. Sometimes just one etiology is found; however, multiple etiologies can coexist. Commonly seen is a combination of vascular dementia and Alzheimer’s dementia, although other combinations can exist.

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UNSPECIFIED NEUROCOGNITIVE DISORDER (799.59) This is the diagnosis when there is a clear neurocognitive disorder but not enough information exists to make a diagnosis as to the etiology of the disorder. The patient may meet the criteria for a major or mild neurocognitive disorder but will not have a clear-cut reason as to why the patient has the symptom complex they have.

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KEY TAKEAWAYS •

Delirium represents a change in attention, cognition, and consciousness that is secondary to a medical condition. It usually comes on rapidly and resolves with adequate treatment of the underlying disorder.

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Major neurocognitive disorder is a severe NCD that affects the individual’s ability to accomplish activities of daily living.

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Mild neurocognitive disorder represents a less-severe form of the disease in which the patient remains relatively independent but needs help with being independent.

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There are many different things that can lead to a mild or major neurocognitive disorder (NCD). These are primary diagnoses, with the NCD diagnosis being secondary.

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QUIZ 1. What is not considered a major feature of delirium? a. Hallucinations b. Cognitive deficits c. Inattention d. Depressed mood Answer: d. These are all features that can be seen in delirium; however, depressed mood is not a major feature. 2. Which condition is least likely to need to be ruled out in delirium because of their similarities to the inattention seen in delirium? a. Amnestic disorders b. Schizophrenia c. Autism spectrum disorder d. ADHD Answer: a. Each of these will have inattention that can mimic delirium except for amnestic disorders, in which there is a normal attention span. 3. Which situation is not consistent with delirium? a. Drug withdrawal b. Coma c. Hypoxia d. Drug intoxication Answer: b. Delirium can be seen in any of these situations but coma and dementia cannot be present if the diagnosis is going to be pure delirium.

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4. What is the most common diagnosis that precedes major neurocognitive disorder? a. Lewy body dementia b. Alzheimer’s disease c. Mild neurocognitive disorder d. Cerebrovascular accident Answer: c. Unless there is a sudden event, such as a stroke or traumatic brain injury, the initial diagnosis is often mild neurocognitive disorder that later progresses to major neurocognitive disorder. 5. What pre-existing finding is least likely to lead to major neurocognitive disorder? a. Major physical illness b. Bipolar mania c. Severe depression d. Severe psychosis Answer: b. Each of these can predict the development of major neurocognitive disorder except for bipolar mania, which doesn’t predict major neurocognitive disorder. 6. Which assessment is not used to diagnose early mild neurocognitive disorder? a. Beck inventory b. SLUMS c. MMSE d. GAF score Answer: a. The Beck inventory is used for the diagnosis of depression, while the others are good tests for detecting early cognitive decline in mild neurocognitive disorder.

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7. What percent of Down syndrome patients will have Alzheimer’s disease after the age of 65 years? a. 10 percent b. 25 percent c. 50 percent d. 75 percent Answer: d. About 75 percent of Down syndrome patients will have Alzheimer’s disease after the age of 65 years as a comorbidity. 8. The patient has dementia with a prominence of social behavioral changes and binge eating. What type of dementia do they likely have? a. Lewy body dementia b. Alzheimer’s dementia c. Frontotemporal dementia d. Parkinson’s dementia Answer: c. These particular changes are mainly seen in frontotemporal dementia, which has behavioral changes as a major feature of the disorder. 9. Which type of dementia has REM sleep disorder as a common early finding? a. Lewy body dementia b. Alzheimer’s dementia c. HIV-associated dementia d. Frontotemporal dementia Answer: a. The different types of Lewy body dementia will have REM sleep disorder as a common early finding.

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10. How long (or later) after the diagnosis of Parkinson’s disease must the onset of dementia be in order to have the diagnosis of Parkinson’s dementia versus dementia with Lewy bodies? a. Six months b. One year c. Two years d. Five years Answer: b. The patient must have Parkinson’s disease at least one year after the diagnosis of Parkinson’s dementia is made. Otherwise, it is called dementia with Lewy bodies.

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CHAPTER SEVENTEEN: PERSONALITY DISORDERS Personality disorders are mental disorders defined as having a rigid and enduring pattern of thinking, behaving, and functioning that is considered out of the norm and that causes difficulty with the patient’s levels of functioning in work, school, relationships, and social activities. The individual is so tuned into their behavior and thinking that they often blame others for their difficulties and don’t recognize themselves as having a disorder. The symptoms often begin in the teens or in early adulthood. There are three major clusters of personality disorders.

CLUSTER A PERSONALITY DISORDERS Persons with cluster A personality disorders often have symptoms of odd or eccentric thinking and behavior that stands out as being out of the norm for most people. There are three personality disorders under this category: paranoid personality disorder, schizotypal personality disorder, and schizoid personality disorder.

PARANOID PERSONALITY DISORDER (301.0) Paranoid personality disorder or PPD involves an individual who has a pervasive lack of trust in others and a significantly cynical view of the world in general. These people are excessively sensitive to social, verbal, or physical attacks, having few people they actually like or love enough to trust. They are argumentative, secretive, excessively rational, unemotional, and aloof with those around them, often doing poorly with group projects or social activities. While they are often critical of others, they respond with hostility or defensiveness if they are criticized by others.

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Brief psychotic reactions can happen to these individuals under stress or duress but it does not last. They do not respond to medications for psychosis and don’t have major deficits in reality testing, even at their worst. The content of their psychotic thinking isn’t bizarre and tends to be paranoid in nature. The disorder does not come out of having endured a traumatic experience so they do not have PTSD, in general. There are two major criteria in the DSM-V for PPD. The first is a global mistrust and suspicion of others which generally starts in adulthood. Four of the seven following sub-criteria must be met: A. Belief that they are being used, lied to, or harmed by others B. Doubts the loyalty or trustworthiness of others C. Lack of ability to confide in others D. Interprets benign remarks as threatening or hurtful E. Holds grudges F. Believes their character is being challenged by other and wants to retaliate G. Jealousy and suspicion of loved ones, believing them to be unfaithful The second criterion is that the symptoms are not part of a psychotic episode in any other mental illness. If the symptoms predate schizophrenia, the diagnosis of PPD is a premorbid one to schizophrenia. The features can be seen in childhood but the diagnosis is not made until adulthood. Interactions with others in childhood that end up in rejection may lead to lack of trust and subsequent lifelong suspicion of others. The prevalence of paranoid personality disorder is 2-4 percent, with a predominance of males. The DSM-V indicates that risk factors for the disorder include having a family history of schizophrenia or persecutory type delusional disorder. There are numerous comorbid personality disorders along with PPD, along with major depressive disorder, OCD, substance use disorders, and agoraphobia. Treatment is difficult with PPD as it is with all personality disorders because they do not see themselves as having a problem. Those who enter treatment will respond to cognitive 266

behavioral therapy, which challenges their maladaptive belief system. In the end, it is difficult to establish rapport with these individuals as they are mistrustful of others. Untreated individuals will have difficulty in workplace, educational, and social settings, often being unemployed or underemployed. They may wish to be intimate with others but know they cannot trust another that intimately.

SCHIZOID PERSONALITY DISORDER (301.20) This is referred to as SPD and is another cluster A disorder. This occurs in less than 1 percent of the general population and involves individuals who stay away from close, personal relationships, choosing instead to remain away and detached from others in society. They engage in solitary activities and choose jobs that keep them away from frequent human-tohuman interaction. They see themselves as societal “bystanders” rather than being involved and active in society. This is not seen commonly, even in psychiatric populations. It is seen more commonly in males and among criminal offenders. No one knows the etiology of this disorder but it does seem to be related to schizophrenia (but not as severe in nature). It has a lot of similarities to the negative symptoms of schizophrenia, such as a lack of emotion, avoidance of others, and lack of motivation. It has some parallel features to other personality disorders, particularly narcissistic, avoidant, and antisocial personality disorders. The major feature is fear of the world with more comfort known by being isolated, secluded, and hidden from the rest of the world. They are extremely submissive and seek validation from within other than from other people. Their apathy often makes them more easily manipulated by others. Their isolation puts them at a higher risk of depression compared to people without the disorder.

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In order for the diagnosis to be made, the individual must have four of the following symptoms: A. Extreme focus on introverted activities B. Does not want to be in close relationships or to be included C. Does not think of sexual experiences D. Anhedonia E. No close friends other than immediate family F. Apathetic to positive or negative feedback from others G. Emotional detachment and coldness, with flattened affect This tends to be more common among men and among individuals with relatives who have schizophrenia. Besides depression, they more frequently get diagnosed at some point in their lives with schizophrenia themselves. Risk factors include heritability, being raised where emotional needs are not met, and being hypersensitive and emotionally disconnected as teens. Many were mistreated as children or were abandoned in childhood. The anxiety these individuals have is related to having fear of close relationships; these people are indifferent to being secluded and do not display strong emotion when wrongly accused of something. They have a greater than average risk of having major depression, anxiety disorders, delusional disorders, and schizophrenia. They are aloof about the need to change and are defiant to therapeutic approaches, making them not really amenable to treatment.

SCHIZOTYPAL PERSONALITY DISORDER (301.22) This personality disorder, called SPD, was covered extensively in Chapter 2 (under schizophrenic spectrum disorders) so it will briefly be touched on here. It is a cluster A disorder that involves individuals who often live in a fantasy world, showing little interest in social activity and leading solitary lives. They have little emotion, are apathetic, and have difficulty expressing themselves emotionally. They may have episodes of psychosis and depression. They tend to withdraw from the idea of relationships and have few intimate friends. It is commonly seen in families that have schizophrenia.

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They may have many acquaintances but few close friends. They are secretive and do not share much with friends or family. Interpersonal problems are common. They may have paranoid characteristics and paranoid delusions. There are deficits in emotional expression and social skills. There is a high rate of suicide, with anxiety disorders, depression, borderline personality disorder, and narcissistic personality disorder.

CLUSTER B PERSONALITY DISORDERS Cluster B personality disorders involve individuals who have overly-emotional, unpredictable, or dramatic thinking or behavior. They include borderline personality disorder, antisocial personality disorder, histrionic personality disorder, and narcissistic personality disorder.

ANTISOCIAL PERSONALITY DISORDER (301.7) Antisocial personality disorder or APD was discussed in detail in Chapter 14 on Disruptive, Impulse Control, and Conduct Disorders. These individuals habitually and pervasively violate and disregard the considerations of others without any remorse. They are often habitual criminals but can be individuals who are simply amoral, who skirt the edges of the law in irresponsible ways and violate social norms and expectations. They make decisions purely on their own desires without considering the needs or negative effects of their actions on others. Patients with APD are not truly antisocial because they are not socially isolated nor are they loners. They are antisocial because they are against society and its rules, laws, and norms. They tend to be attractive, highly charismatic, and good at gaining others’ sympathies, often stating they are the victims of injustice when, in fact, they are perpetrators. They often have higher than normal intelligence and use their cunning against others through manipulation and exploitation. They may be empathetic of their victim’s suffering but derive pleasure from this. Those with some positive empathy are sometimes amenable to treatment.

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BORDERLINE PERSONALITY DISORDER (301.83) This is a complex disorder that impacts the individual’s sense of self and their interpersonal relationships. They have an intense fear of abandonment, which is a major feature of their personality difficulties. It is almost always seen in women. They engage in many impulsive and unsafe behaviors in an attempt to avoid abandonment. There are frequent suicidal threats and attempts within this population. Self-injury is a coping strategy in patients with this problem. This is a pervasive pattern of instability of interpersonal relationships, affect, and self-image that begins in early adulthood and affects many areas of their life. They are fearful of abandonment and try to avoid becoming abandoned. There are frequent and intense changes in relationships in which the person exhibits strong love or hateful feelings toward their romantic partners. This extends to their doctors, relatives, and others in their lives. They have a distorted or weak sense of self as demonstrated by dramatic changes in goals, values, and interests. Healthy relationships might be destroyed and other self-destructive behavior happens. There may be reckless driving, binge eating, unhealthy spending, unsafe sex, and substance abuse. Self-injurious behavior is common. Disproportionate anger and temper tantrums can be seen as well as dissociative symptoms and paranoia. The prevalence is about 2 percent of the population but is much higher among psychiatric patients. There is a great deal of morbidity and mortality associated with borderline personality disorder, including an 8-10 percent suicide rate and many attempts at suicide and self-mutilation. Selfinjury is seen in up to 60 percent of teens with mental illness but this doesn’t always mean they have BPD. The treatment for the disorder is dialectical behavioral therapy or DBT, which involves a whole-systems approach. DBT teaches new coping skills from a position of understanding and empathy; it is considered the most effective therapy for treating this disorder. Group DBT will teach interpersonal skills. Because recurrent crises are typical of this disorder, having a therapist that can be reached is important.

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HISTRIONIC PERSONALITY DISORDER (301.50) These are patients who display dramatic and attention-seeking behavior in order to gain the approval of others. They may be particularly flirtatious, seductive, or excessively emotional in order to gain the attention of those around them. The behavior is over-the-top with extreme self-centeredness and displays of temper that interfere with relationships. They are excessive in their attention to their appearance and display narcissistic qualities. They assume more familiarity with strangers and others than people without the disorder. It is more commonly seen in women and affects 1-3 percent of the US population. Symptoms of the disorder include having several of the following: A. Shallow, changeable emotions B. Excessive intimacy with others C. Hypersensitivity to criticism D. Manipulative behavior E. Sexual provocativeness F. Disproportionate emotional reactions G. Compulsive desire for attention H. Preoccupation with appearance I. Easily influenced and suggestible J. Compulsion to be the center of attention Factors that play into developing histrionic personality disorder include genetics and the inheritance of excitement-seeking and neurotic behavior. Parental influence also plays a role so that emotionally shallow parenting might be a factor. There are a lot of overlaps with this disorder and antisocial personality disorder with the suggestion that they might have similar etiologies. Childhood trauma plays a role in this disorder as it does in other personality disorders.

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Comorbid personality disorders with HPD include borderline personality disorder, narcissistic personality disorder, and dependent personality disorder. Other comorbidities include major depressive disorder, somatic symptom disorder, and conversion disorder. These patients may also misuse substances or may develop anorexia nervosa. The onset of the disease is late teens to early twenties. The individual may seem charming and are able to function well in many social circles but will have more difficulty in their personal life and with romantic relationships. They often struggle to deal with failure and loss, frequently getting bored in ordinary situations and in relationships. They crave new experiences and excitement, leading to depression and risk-taking behavior. The patient often seeks treatment for things like depression and anxiety—not for the personality disorder itself. Still, they can be managed with cognitive behavioral therapy, support groups, and functional analytic psychotherapy. Medication is generally used for depression and anxiety symptoms, which can be coexisting with the personality disorder.

NARCISSISTIC PERSONALITY DISORDER (301.81) This is a cluster B disorder that is not frequently diagnosed. These individuals seek psychiatric care for anxiety and depression—not for their personality disorder. It is a relatively recent diagnostic category that represents a subgroup of difficult-to-treat patients that do not easily respond to traditional psychotherapeutic treatment options. It is seen more commonly in males than females; it is seen more in clinical practice than it is seen in research circles. The major feature is grandiosity and the need for excessive admiration from others. There is a genuine lack of empathy for other individuals. It can negatively impact the patient’s interpersonal and work life, as well as their social life. They are condescending and denigrating, needing to be in control and frequently dismissing the needs and wishes of others. Internally, however, they feel a great sense of inadequacy and low self-esteem. They do not handle disapproval or rebuff of any kind.

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According to the DSM-V, there must be five of these nine characteristics to make the diagnosis, which usually begins in early adulthood: A. Grandiose sense of self-importance B. Fixated on fantasies of infinite control, success, or idyllic love C. Belief that they are extraordinary and exceptional D. Desire for unwarranted admiration E. Having a sense of entitlement F. Interpersonally oppressive behavior G. No sense of empathy H. Resentment toward others and the belief that others resent them I. Egotistical and conceited behaviors or attitudes The prevalence is less than one percent in the general population with similar characteristics to the other cluster B personality disorders. Many will also have an Axis I disorder, such as substance use disorder, depression, or anxiety. About half of all patients seen will have major depression at the time of diagnosis. About 5-10 percent will have bipolar disorder and up to two-thirds of patients will have a substance use disorder. The treatment of NPD involves drug therapy and psychotherapy. Psychoanalytic psychotherapy tends to be the most effective; however, other types of therapy will help the disorder. Group therapy is not successful as these individuals do not have the skills for dealing with others in a group setting. There are no drugs for the treatment of NPD; however, many are treated with antidepressants, antipsychotics, and mood stabilizers to treat their comorbid disorders. Most will need long-term monitoring as they can have a chronic suicide risk because of their ongoing psychopathology.

CLUSTER C PERSONALITY DISORDERS Patients with cluster C personality disorders have anxiety with fearful thinking or behavior. They include avoidant personality disorder, dependent personality disorder, and obsessive-

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compulsive personality disorder.

AVOIDANT PERSONALITY DISORDER (301.82) Avoidant personality disorder involves pervasive inadequacy and hypersensitivity to being negatively judged by others. There is extreme shyness that is the major feature of the disorder. This is present in many situations and affects the person’s social, occupational, and interpersonal life. They desire social connection but have so much personal inadequacy that they fear social rejection. They see themselves as being defective and unlikable so that others are likely to reject them. It may be a severe form of social anxiety disorder. In the general population, about 2 percent of people have this, with about 10-20 percent of psychiatric patients being affected by the disorder. It is included as a cluster C disorder because it involves anxiety, fearfulness, and internalization of distress. They tend to choose isolation because they don’t want to risk being negatively evaluated. There are seven criteria for the disorder and four of them must be met to make the diagnosis: A. Avoids occupational activities involving significant interpersonal contact because of fear of rejection or disapproval from others B. Unwilling to get involved with people unless they are guaranteed of acceptance C. Shows restraint within intimate relationships out of fears of shame or ridicule D. Preoccupied with fears of rejection in social situations E. Feels inferior to others, socially inept, or personally unappealing F. Feels inadequate in interpersonal situations G. Reluctant to take risks or to engage in new activities out of fear of being embarrassed The treatment of avoidant personality disorder involves individual psychotherapy, which helps them become less sensitive to rejection. They believe that rejection will be unbearable so they don’t seek treatment because they think the therapist will not like them. They are very sensitive to criticism in therapy and might see the therapist as being critical without basis. They do not

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see the therapist’s genuine concern so they run the risk of terminating therapy prematurely.

DEPENDENT PERSONALITY DISORDER (301.6) This is a diagnosis given to individuals who are excessively needy and dependent on others. The patient will have dependence on others early in life that is developmentally appropriate but will continue to have these feelings after they have grown to adulthood. The individual is usually able-bodied and not otherwise psychologically impaired so they have no particular reason to be dependent. There are eight features for the disorder that involves one specific criterion, which is an excessive need to be taken care of or to be submissive and clingy. Features of this criterion involve the following: •

Difficulty making routine decisions without advice or input from others.

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Needs others to assume responsibilities that they should be attending to.

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Fear of disagreeing with others, risking disapproval.

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Difficulty starting projects without support from others.

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Need for nurturance and support from others.

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Feels helpless and vulnerable when alone.

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Seeks out a new relationship when one ends.

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Preoccupation with being left alone and unable to care for themselves.

This disorder can appear in adolescence or early adulthood with a lack of the normal autonomy that individuals have at this age. They rely on others to make decisions for them and do not step up to normal levels of responsibility. The prevalence is about 0.5 percent, seen more frequently in females than in males. The only known risk factor is being female, although having authoritarian parenting where decisions were made for them at a developmentally inappropriate age. There are no specific comorbidities except for substance use disorder, which is a comorbidity of all personality disorders.

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Individuals with dependent personality disorder often tolerate situations from which others would usually withdraw, including verbal, sexual, and physical abuse. As such, they are at risk for spousal abuse as they are dependent on abusive spouses. Some will view them with pity, while others easily get frustrated with their lack of ability to make their own decisions. They tend to become involved in unhealthy relationship dynamics. There are enough overlapping features between DPD and other personality disorders, such as borderline personality disorder and histrionic personality disorder so these need to be ruled out. There are also cultural issues in which dependency in women is highly regarded. They may be seen as overly dependent in an American cultural setting.

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (301.4) This is a cluster C disorder because it involves anxiety and fear. The patient with obsessivecompulsive personality disorder is perfectionistic and is preoccupied with orderliness. There is a need for control—both mentally and interpersonally. They need sameness and control that results in a loss of flexibility in daily living. There are lists, rules, schedules, and a need for control that is so severe that the original purpose of the task is easily forgotten. They can be overly obsessed with work and productivity to the point of complete exclusion of leisure activities and interpersonal relationships. One feature of this order is a need to hang onto their money, being reluctant to discard objects than no longer have any value. In this way, they are at risk for pathological hoarding. Patients with this disorder do not usually seek help unless there is significant distress or impairment in functioning. It is difficult to differentiate obsessive-compulsive personality disorder and OCD, except that people with OCD have true obsessions that aren’t really seen in the personality disorder. Patients with OCPD will often also receive the diagnosis of OCD, particularly if they have true obsessive thoughts and compulsive actions. If symptoms of both disorders are present, they are coded for separately under the DSM-V. Another comorbidity is hoarding disorder.

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Sometimes drug use or CNS disorders cause these symptoms so these need to be ruled out. Certain anxiety disorders, such as hypochondriasis and anorexia nervosa can be linked to OCPD. This is perhaps the most prevalent personality disorder, affecting about 2-8 percent of the population. It may be underreported as people with OCPD do not seek treatment as long as they can manage their symptoms without help. The treatment of the disorder is difficult as many do not want to change these features of their personality. Treatment focuses on the use of CBT or other therapy in order to identify sources of stress and to learn interpersonal coping strategies. While anti-anxiety medications are helpful in OCD, it isn’t clear that it actually helps people with symptoms secondary to having the personality disorder.

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KEY TAKEAWAYS •

The patient with a personality disorder has an enduring and pervasive collection of features beginning in adolescence or early adulthood that are often maladaptive.

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There are three clusters of personality disorders, called cluster A, cluster B, and cluster C.

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Cluster A patients have odd or eccentric thoughts and behaviors. The disorders include paranoid, schizoid, and schizotypal personality disorders.

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Cluster B patients have overly-emotional, unpredictable, or dramatic thinking or behavior. They include borderline personality disorder, antisocial personality disorder, histrionic personality disorder, and narcissistic personality disorder.

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Cluster C patients have a lot of anxiety and fear ruling their thinking. These include avoidant, dependent, and obsessive-compulsive personality disorders.

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QUIZ 1. Which personality disorder is not a Cluster A personality disorder? a. Schizotypal personality disorder b. Narcissistic personality disorder c. Paranoid personality disorder d. Schizoid personality disorder Answer: b. Cluster A individuals have odd or eccentric thinking or behavior. This cluster includes each of the following except for narcissistic personality disorder. 2. The individual has an enduring mistrust of others. What personality disorder is this most characteristic of? a. Paranoid b. Schizoid c. Borderline d. Narcissistic Answer: a. People with PPD or paranoid personality disorder have a pervasive and enduring mistrust of others. 3. Which personality disorder is considered the rarest among those listed? a. Paranoid PD b. Schizoid PD c. Borderline PD d. Narcissistic PD Answer: b. Schizoid PD is rare, seen in less than one percent of the general population, more commonly seen in males.

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4. Which personality disorder involves social isolation and a rich fantasy life? a. Narcissistic personality disorder b. Avoidant personality disorder c. Schizotypal personality disorder d. Borderline personality disorder Answer: c. Patients with schizotypal personality disorder are secretive, socially isolated, and have a rich fantasy life. 5. Which personality disorder is characterized by an intense fear of abandonment? a. Avoidant personality disorder b. Borderline personality disorder c. Narcissistic personality disorder d. Dependent personality disorder Answer: b. Individuals with borderline personality disorder will have an intense fear of abandonment as a major feature of the disorder. 6. What type of therapy has been found to be the most effective in treating patients with borderline personality disorder? a. Cognitive behavioral therapy b. Psychodynamic therapy c. Dialectical behavioral therapy d. Family systems therapy Answer: c. DBT teaches emotional regulation and mindfulness to patients with borderline personality disorder; it is the most effective treatment for these patients.

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7. Which personality disorder primarily involves an intense sense of grandiosity? a. Avoidant PD b. Borderline PD c. Dependent PD d. Narcissistic PD Answer: d. Narcissistic PD is seen mainly in males and is evidenced by a sense of grandiosity. 8. Which comorbidity is most likely to be seen with individuals with narcissistic personality disorder? a. Major depression b. Bipolar disorder c. Substance-use disorder d. Anxiety disorder Answer: c. About two-thirds of NPD patients will meet the criteria for having a substance use disorder. 9. Which treatment is most helpful in treating avoidant personality disorder? a. Dialectical behavioral therapy b. Group therapy c. Psychoanalytic therapy d. Individual psychotherapy Answer: d. These patients need to learn how to maneuver an interpersonal relationship with a therapist so they can gradually strengthen their ability to be intimate with someone without fear of rejection.

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10. What is the major feature seen in patients with dependent personality disorder? a. Fear of rejection from others b. Worries about abandonment c. Needs to be taken care of by others d. Fears interpersonal intimacy Answer: c. The patient with dependent PD will be needy and will have an excessive need to be taken care of by others.

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CHAPTER EIGHTEEN: PARAPHILIC DISORDERS This chapter involves a discussion of paraphilias or paraphilic disorders. These are a collection of related disorders that involve sexual deviancy. Individuals with a paraphilic disorder have a specific urge to engage in sexually-related behaviors that are considered out of the norm for modern society. They include things like voyeurism, transvestism, fetishism, frotteuristic disorder, and both sexual sadism and sexual masochism. People with these disorders are intensely aroused by things that most people are not aroused by.

VOYEURISTIC DISORDER (302.82) This is also referred to as “voyeurism” and refers to an intense urge to spy on others in their home or during other private activities. This is a paraphilia because it gives the person sexual satisfaction from seeing others undressing, naked, or engaged in sex in their home or other private place. Rarely, the observed individual is consenting but the major purpose of sexual gratification surrounds the idea that the other person does not consent and is unaware they are being observed. A person may have voyeuristic tendencies but will not have the disorder unless there is significant distress or problems with significant areas of everyday functioning. The diagnosis is not made unless the patient gets most of their sexual satisfaction from observing unsuspecting persons and has done so for a minimum of six months. There must also be stress or impairment in their life and they must have observed a minimum of three unsuspecting targeted individuals during the six-month period. The individuals must be disrobing, naked, or engaging in sex. About half of all individuals will deny their voyeuristic tendencies. Having a legal history of being caught with voyeuristic behavior also adds to make the diagnosis.

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Many individuals who refuse to disclose their tendencies toward voyeurism will claim that the observation was nonsexual in nature or accidental. According to the DSM-V, these individuals are probably denying also that they’re having distress and/or social impairment and can still be diagnosed with voyeuristic disorder. This is the most common illegal sexual behavior, which has temperamental and environmental risk factors. There are tendencies toward voyeurism that go along with a history of hypersexuality, childhood sexual abuse, and substance abuse. Comorbid states include just about any other paraphilia, particularly exhibitionistic disorder, although many other psychiatric conditions are comorbid with this disorder. The treatment options for voyeuristic disorder include marital therapy, group therapy, cognitive therapy, psychotherapy, and other therapy types. Psychopharmacology is used to decrease sexual hormones. The paraphilias are all related to OCD and so SSRI drugs are considered firstline therapies for the treatment of this disorder.

EXHIBITIONISTIC DISORDER (302.4) The DSM-V classifies Exhibitionistic Disorder as having the inordinate need to expose one’s genitals to another person—usually to an unsuspecting stranger, resulting in sexual satisfaction for the exhibitionist. Almost all exhibitionists are males and some wish to be observed while having sex. It starts in the late teens or early adulthood and may be something that is deliberate or unconscious. Exhibitionistic disorder is different from having exhibitionistic tendencies. According to the DSM-V, the behaviors linked to Exhibitionistic Disorder happen over a sixmonth period of time, are recurrent, and result in an intense feeling of sexual satisfaction after exposing one’s genitals to a stranger. It is deliberately intended to do this behavior with a nonconsenting individual. This can occur in children and in adults; it needs to cause distress or impairment in functioning to qualify as having the disorder.

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This is a lifelong disorder that has a high rate of recidivism, despite treatment. It is difficult to treat the patient well enough to modify and/or control their behavior. Family members need to be involved in managing the behavior by limiting internet access and restricting all substances. Regular therapy is necessary to contain the behavior and to recognize triggers for the behavior. Some individuals may spontaneously remit. Comorbidities include substance abuse and the various mood disorders. The patient may exhibit suicidal behavior upon being arrested or incarcerated. Various drugs have been tried with some success, particularly SSRIs. Antiandrogens may also be prescribed to decrease testosterone production.

FROTTEURISTIC DISORDER (302.89) Frotteuristic disorder is defined as a “courtship disorder” in which the patient demonstrates sexual arousal by touching or rubbing against a nonconsenting individual. There are fantasies around touching people. They tend to touch people in public places, such as in crowds or on mass transportation vehicles. The symptoms must last at least six months to qualify as having the disorder. Distress and/or impairment of function must be present to make the diagnosis. Full remission is the non-action of urges for a minimum of five years. To make the diagnosis, the touching of a nonconsenting person must have had to occur on at least three occasions and must be distressful to the patient. If distress and impulses have occurred and the patient hasn’t yet acted on it, they could be diagnosed with frotteurism; individuals who deny their behaviors despite evidence can also be diagnosed with the disorder. The symptoms start in late adolescence and may not initially involve sexual arousal. Other sexual impulse disorders (hypersexuality, exhibitionism, and voyeurism) can be comorbid, as can antisocial personality disorder, conduct disorder, substance abuse disorders, and mood disorders. This is a very common behavior, affecting up to 30 percent of adult males, who do not meet the criteria for the actual frotteuristic disorder. Patients with paraphilias have a 10-15 percent chance of also having frotteuristic disorder. It is almost exclusively seen in males and perpetrated upon women. The prevalence of frotteuristic behavior is unknown because many 285

individuals keep their behavior subtle and are private about their fantasies. Treatment can involve giving female hormones or antiandrogens, SSRIs, and antipsychotic drugs in an attempt to reduce the sexual fantasies and to redirect the behavior. Lifelong psychiatric and psychological support is usually necessary as the individual has only a rare chance of true resolution of their fantasies. There is a high likelihood for legal consequences if the patient gets caught and convicted of a sex crime.

SEXUAL MASOCHISM DISORDER (302.83) This involves a patient who has sexual arousal after receiving extreme pain, bondage, torture, or humiliation in a sexual way. They may have recurrent and persistent urges and fantasies related to being beaten or otherwise mistreated during sex. The behaviors are actually very common; however, as with all of these types of disorders, the patient must experience extreme distress or impairment of function in order to have the “disorder.” Mild masochism between consenting adults is not considered a disorder. The individual with SMD (sexual masochism disorder) has recurrent fantasies or behaviors of extreme pain, torture, or humiliation. It must be present for six months and must be distressful or impair social functioning. There is a specifier to include asphyxiophilia (arousal by asphyxiation). If the behavior involves self-inflicted harm, it must be for the purposes of being sexually aroused. Individuals often enjoy pornography related to masochism. The patient must admit to having these fantasies and urges in order to make the diagnosis. The average age at onset of the disorder is 19 years, although fantasies and urges can happen as young as 12 years of age. It can involve an individual into BDSM (bondage discipline sadism and masochism) but there needs to be distress, guilt, or shame in the behavior in order to have sexual masochism disorder. Some men with the disorder will hire a dominatrix to engage in this fantasy disorder. The dominatrix rarely has actual intercourse with the individual who needs to be humiliated in order to be aroused.

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The actual prevalence of the disorder is unknown; however, 12 percent of women and 25 percent of men report fantasies centered around masochism. About half of consenting adults enjoy being bitten or scratched as part of sexual play. The prevalence of this behavior is higher among women who are lesbians or bisexuals. Having distress around the behavior is a requirement for the diagnosis. The biggest risk is injury to the patient, particularly in cases of autoerotic asphyxia. This is the leading cause of death due to the disorder, often occurring during masturbation. The treatment can involve antiandrogen therapy to control hypersexuality and be more receptive to psychotherapy or to reduce the chances of injury or death related to the behavior. Drug therapy does not involve a long-term solution but does help psychotherapeutic goals. Journaling of fantasies is helpful to the therapeutic process. Psychoeducation and sexual education along with social skills training can help resolve the behavior.

SEXUAL SADISM DISORDER (302.84) In cases of sexual sadism disorder, the individual has an algolagnic disorder in which there is sexual arousal by inflicting physical and/or psychological suffering upon another person. There is intense sexual excitement by the fantasizing over or witnessing of physical or psychological harm to another, who may or may not be consenting. It must be present for six months to qualify as being a sexual paraphilic disorder, with the diagnosis made when there is distress, impairment of functioning, or an act upon a nonconsenting individual. Specifiers involve whether the patient is in a controlled environment (such as incarceration) or has been symptom-free for five years without distress. There is a scale called the SSSS (Severe Sexual Sadism Scale) that indicates the propensity toward the disorder. The patient can deny their fantasies and their behavior and will still meet the criteria for the disorder but the differential diagnosis involves sadism versus a nonsadistic sexual assault. Mild forms of pain between consenting adults does not qualify as sexual sadism disorder.

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Sexual sadism disorder is comorbid with other paraphilic disorders (with no clear prevalence of any one). Most of the research data comes from incarcerated males who have perpetrated sadistic crimes so it may not be representative of most men who have the disorder. There is little information on females with the disorder. There seems to be an impairment in emotional recognition and processing (as well as increased aggression levels) in individuals who have this illness. Less than 10 percent of convicted sex offenders have sexual sadism disorder; however, the incidence is as high as 75 percent in those who have committed a sexually motivated homicide. Treatment is primarily through drug therapy, such as female hormones and anti-androgen drugs. These will reduce the sexual impulses and improve the resultant behavior. There is a high rate of recidivism among people who get sexually aroused when exposed to violent content. These types of patients need ongoing monitoring if they are not incarcerated in order to avoid acting on their sexual fantasies of harming others.

PEDOPHILIC DISORDER (302.2) This is a diagnosis given to individuals who are at least sixteen years of age or older who are sexually aroused by prepubescent children. Any expression of the patient’s fantasies is a criminal offense in most parts of the world. There may be a difference between individuals who have desires that are ego-dystonic and individuals who indulge in their fantasies by possessing child pornography and who associate with other pedophiles. This is a highly treatment-resistant disorder with a great deal of recidivism (as high as 50 percent). This may not be accurate as some do not come to the attention of law enforcement, while others are incarcerated. This is an extremely damaging disorder for the victims, many of whom have lifelong sexual problems and PTSD. Some believe it is a psychological/sexual preference, while others hold a more moral approach, indicating that this represents criminal behavior. The differentiating factor is whether or not the individual acts on their fantasies. A “predatory pedophile” acts on their sexual desires. Others believe that pedophilia is a repressed sexual orientation that is amenable to treatment. 288

There are three criteria with five specifiers in the DSM-V. The three criteria include: 1) having arousing fantasies or behaviors with a prepubescent child; 2) having acted on the desires or significant distress around these desires; and 3) is at least five years older than the child and sixteen years of age. The five specifiers include the following: •

Sexually attracted to children only

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Sexually attracted to adults and children

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Attracted to boys

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Attracted to girls

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Incestuous only

The onset of the disorder is around puberty with a prevalence of about 3-5 percent in the adult population. There is a correlation between this disorder and antisocial personality disorder. Many will have been victims as children. The DSM-V indicates a high risk of comorbidity with mood disorders, substance use disorders, anxiety disorders, and other paraphilias. It is not amenable to psychotherapy. Chemical and physical castration do not necessarily stop the behaviors.

FETISHISTIC DISORDER (302.81) This involves an individual who is sexually aroused by an object or body part AND who is distressed by their fantasies or behavior. The object or body part is not considered erotic to the average person; almost anything can be the object of the individual’s desires. The sufferer of fetishistic disorder may involve gratification in the absence of a partner. This is seen almost exclusively in men with homosexuality seen in 25 percent of those who have the disorder. There are three criteria for fetishistic disorder with four specifiers. The three criteria include the following:

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a. Having sexual urges focused on a non-genital body part or object for six months (and has acted them out) b. Having distress or impairment of function c. The object is unrelated to transvestic disorder and is not a sexual stimulation device Specifiers include the type of object that is the focus of the fantasy, whether there are other behaviors associated with acting out of the fantasies (like smoking or other behavior), if the patient is in a controlled environment, and if the patient has been in remission for five years. The onset is around the time of puberty but can begin earlier than that. It tends to wax and wane over the patient’s lifetime and is seen in males almost exclusively. It can be co-occurring with other paraphilias and may be linked to early sexual encounters and anticipation associated with sex. It is best treated with cognitive behavioral therapy and often impacts intimacy in a relationship. In order to make the diagnosis, transvestic disorder and sexual masochism need to be ruled out as does having fetishistic behavior (but not the actual disorder).

TRANSVESTIC DISORDER (302.3) This is a specific paraphilia in which the patient is sexually aroused by dressing in clothing of the opposite sex and has a great deal of distress because of it. The symptoms must be present for six months to make the diagnosis. The act of cross-dressing must bring about feelings of sexual arousal. This must be differentiated from gender dysphoria, in which the patient feels they are the opposite gender. It can involve just one item of clothing or everything from clothing to hair to makeup. It is different from fetishistic disorder because the target of the fetish in some cases of fetishism is the actual woman’s clothing object and not dressing in it. The disorder is often seen in childhood and intensifies in puberty. The level of arousal peaks in puberty and lessens over time. The longer the person has the disorder, the longer they want to portray the feminine role. This is a very rare disorder and is usually seen in heterosexual males. Comorbid disorders with transvestic disorder include autogynephilia (fantasizing and being a woman), masochism, and fetishism. A greater than average proportion of these people will die 290

from autoerotic asphyxiation, which can coexist with the disorder. It is seen in about three percent of males. The diagnosis requires distress around the cross-dressing behavior. Transvestic disorder is treated with a combination of psychotherapy to deal with the urges and fantasies, antiandrogens to control hypersexuality, and SSRIs to control the obsessions associated with wanting to cross-dress. Depression and suicidality need to be managed as these are men who want a heterosexual relationship and who often have interference with their relationships because of their behavior.

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KEY TAKEAWAYS •

Paraphilias represent sexual urges and desires that either harm another, harm the patient, or cause distress in the person who has it.

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In general, the object of the sexual desire of the patient falls outside of societal and social norms.

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The patient needs to have the symptoms for six months in order to qualify as having a paraphilia.

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Some paraphilias are inherently illegal and come to the attention of the criminal justice system.

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QUIZ 1. What is the major feature of voyeuristic disorder? a. Watching a loved one who consents to be observed undressing or engaging in sex. b. Participating in a sex act with two or more consenting adults. c. Undressing in front of another person who is not consenting. d. Observing another person in private activities who is not consenting. Answer: d. The main goal of getting sexual satisfaction in voyeuristic disorder is to observe another who is not consenting and is unaware that they are being observed. 2. How long must a patient have voyeuristic tendencies in order to make the diagnosis of the disorder? a. One month b. Three months c. Six months d. One year Answer: c. The patient needs to exhibit voyeuristic tendencies for six months to make the diagnosis of voyeuristic disorder. 3. What does not increase the risk of voyeuristic disorder? a. Major depressive disorder b. Hypersexuality c. Substance use disorder d. Child sexual abuse

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Answer: a. Each of these is a risk factor for voyeuristic disorder except for major depressive disorder, which does not seem to be seen more frequently as a risk factor for this disorder. 4. What treatment most diminishes sexual fantasies in individuals with exhibitionistic disorder? a. Antiandrogens b. SSRIs c. Mood stabilizers d. Typical antipsychotics Answer: a. Antiandrogen therapy will decrease testosterone, decreasing the sexual drive and reducing fantasies in patients with exhibitionistic disorder. 5. How long a period of time of non-action on sexual fantasies must there be in frotteuristic disorder in order to consider the patient in full remission? a. Six months b. One year c. Five years d. Ten years Answer: c. If the patient hasn’t acted on their tendencies for five years, they are said to be in full remission. 6. Which is least likely to be defined as a sexual impulse disorder? a. Voyeurism b. Sexual sadism c. Exhibitionism d. Frotteurism

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Answer: b. Each of these is a typical sexual impulse disorder except for sexual sadism. 7. What percent of sex offenders are believed to have sexual sadism disorder? a. 10 percent b. 25 percent c. 50 percent d. 75 percent Answer: a. Fewer than ten percent of individuals who are sex offenders actually have sexual sadism disorder. The prevalence is as high as 75 percent in those who have committed a sex-related murder. 8. How old does a person have to be in order to be diagnosed as being a pedophile? a. 14 years b. 16 years c. 18 years d. 21 years Answer: b. The diagnosis can be made in individuals as young as sixteen years. It primarily involves male offenders. 9. What is not a criterion of pedophilic disorder? a. Sexual desires/arousal related to prepubescent children b. Being at least five years older than the victim and 16 years of age or more c. Acting on their desires or being distressed by them d. Being exclusively attracted to children Answer: d. The individual does not have to be exclusively attracted to children but must meet the other three criteria to be called having pedophilic disorder.

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10. Which is not associated with transvestic disorder? a. Pedophilic disorder b. Masochism c. Autoerotic asphyxiation d. Fetishism Answer: a. Each of these is seen with transvestic disorder except for pedophilic disorder, which is not a comorbid state.

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CHAPTER NINETEEN: MEDICATION-INDUCED MOVEMENT DISORDERS (DIMD) The subject of this chapter was added to the DSM-V because of the high prevalence of movement disorders as a result of a wide variety of drugs that can cause medication-induced movement disorders. The classic drug classification considered causative of most movement disorders is that of dopamine blockers used in the treatment of psychotic disorders. There is medication-induced akathisia and medication-induced acute dystonia, which also comes from using these medications.

TYPES OF MOVEMENT DISORDERS The type of drug most likely to cause a movement disorder is a dopamine antagonist or “dopamine receptor-blocking drug,” which can cause acute or late-onset symptoms. Acute symptoms come from suddenly starting or increasing the dose of the dopamine (D2) receptor. Typical antipsychotics are most commonly associated with these types of reactions. Typical acute reactions include parkinsonism, dystonia, akathisia, and neuroleptic malignant syndrome (NMS). Late onset or “tardive” movement disorders take about three months or more after exposure to the drug. The dosage is usually stable but there can be an increased dosage being causative or stoppage completely of the drug. The classic tardive dyskinesia is referred to as stereotypy. Other movements include chorea, dystonia, akathisia (and others). Tardive dyskinesia or “extrapyramidal symptoms” refer to the oral-buccal-lingual movements or facial dyskinesia that can come primarily from typical antipsychotics but can also come from atypical antipsychotics.

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Drug-induces dystonia involves having an abnormal posture and/or twisting movement of the limbs, face, neck, eyes, throat or jaw. Stridor and dyspnea can occur in severe cases. It occurs about 2-5 days after starting a dopamine receptor blocking drug or DRBD. Drug-induced Parkinson disease or parkinsonism involves having all the typical symptoms, including bradykinesia, rigidity, postural instability, and resting tremor. Cessation of the drugs will cause resolution of the symptoms in most cases, although it can take in excess of 18 months to resolve the symptoms. Classic tardive dyskinesia involves lip smacking, tongue thrusting, and cheek puffing. Jaw movements may resemble chewing motions with lateral movement. Trunk movements are also seen, particularly choreoathetoid movements (writhing or twisting movements). Some patients may also have typical tardive dyskinesia, myoclonus, parkinsonism, and dystonia. Akathisia is restlessness and stereotypic movements is almost always drug-induced; it is not seen as an idiopathic disease state. This is not true of other movement disorders. Neuroleptic malignant syndrome is a sudden-onset, life-threatening reaction that occurs in 0.2 percent of patients after receiving a normal amount of a DRBD. The symptoms include hyperthermia, muscle rigidity, mental status changes, autonomic dysregulation, and other movement disorders. The prevalence of drug-induced movement disorder symptoms is unknown as it is believed to be vastly underappreciated and underdiagnosed. This is especially true of patients in a nursing home. Symptoms can wax and wane, while other drugs can mask the symptoms, making it underestimated. Factors that affect the rate of DIMD (drug-induced movement disorder) include the age of the patient, the type of drug, and the dose. The incidence is up to 42 percent after using typical antipsychotics and about 19 percent after receiving atypical antipsychotic drugs. About 9 percent of children on an antipsychotic will develop tardive dyskinesia. Kids have a higher incidence of extrapyramidal symptoms with neuroleptic use of at least six months. Remember that tardive dyskinesia is likely irreversible. 298

PATHOPHYSIOLOGY AND DIAGNOSIS OF DIMD No one knows the exact pathophysiology of DIMD but there may be a genetic predisposition that results in dopaminergic hypersensitivity in the basal ganglia and over-activation of the cholinergic system. The differential diagnosis of DIMD is the same as movement disorders that aren’t related to medications. The movement disorder is first diagnosed and then the temporal relationship between acute use or chronic use of neuroleptic drugs. The movement disorder manifests the same way as those not secondary to drugs. Remember that only akathisia has no known idiopathic counterpart. The movement disorder is most likely to be relate to drug use if there are both hypokinetic and hyperkinetic movements (such as parkinsonism and tardive dyskinesia) at the same time. The axial distribution of dystonia is more likely seen in tardive dystonia secondary to drug use. Oral buccal lingual movements are seen primarily with movement disorders secondary to drugs. The parkinsonism happens subacutely. The history should include the recent use of neuroleptics, anesthesia, anti-nausea drugs, weight-loss drugs, or antidepressants.

TREATMENT OF DIMD This is an iatrogenic condition with withdrawal of the drug as the most common treatment. The drug can also be given at a lower dose or an alternate drug choice given. With tardive dystonia the symptoms often do not resolve after stopping the drug so that prevention of these symptoms should be part of the plan from the beginning. The need for the drug should be weighed against the need for stopping the movement disorder. Switching from a typical to atypical antipsychotic can resolve the symptoms in many cases. The treatment of tardive dystonia, tardive akathisia, and tardive dyskinesia include tetrabenazine and reserpine, which are amine-depleting drugs. These are used when withdrawal alone does not resolve the symptoms. Tetrabenazine has been FDA-approved for individuals with chorea in Huntington’s disease. These drugs work best when the drug is already withdrawn or withdrawn at the same time. 299

MEDICATION-INDUCED AKATHISIA (333.99) This is a DSM-V diagnosis used for akathisia secondary to dopamine receptor antagonist antipsychotic drugs. The pathophysiology is ot well understood but it appears to be directly related to the dopaminergic neurotransmitter system. Drugs used to treat this type of movement disorder include serotonin antagonists, beta blockers, and benzodiazepines. Restless legs syndrome appears to be related to this disorder but is located primarily in the legs. Other drugs that can involve akathisia include antidepressants that affect the serotonin pathway. Serotonin antagonists can successfully treat this movement disorder. Still other drugs that can be contributory to akathisia include SSRIs, tricyclic antidepressants and miscellaneous antidepressants, antiemetics, opiate withdrawal, benzodiazepine withdrawal, cocaine withdrawal, and barbiturate withdrawal.

MEDICATION-INDUCED ACUTE DYSTONIA (333.72) This is an acute movement disorder that can be a side effect of early treatment with antipsychotic and other drugs. Antiemetic and antidepressant drugs can cause this as well. It is diagnosed within seven days of starting or increasing the drug supposedly the cause of the movement disorder. The treatment of choice (other than withdrawing the drug) is to give Biperiden intramuscularly, which is effective within twenty minutes. Risk factors for acute druginduced dystonia include young age, male gender, use of cocaine, and history of the disorder in the past. Atypical antipsychotics have a much lesser degree of causing acute dystonia when compared to typical antipsychotics.

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KEY TAKEAWAYS •

The phenomenon of medication-induced movement disorder involves abnormal movements after taking an antipsychotic drug, although other psychotropic drugs can cause this problem.

•

The movement disorder can be acute or tardive. If tardive, it takes about three months to develop the symptoms.

•

Sometimes the movement disorder does not resolve after stopping the drug. This is especially the case for tardive dystonia and sometimes with tardive dyskinesia.

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The DSM-V recognizes medication-induced akathisia and medication-induced acute dystonia as separate disorders in this classification.

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QUIZ 1. Which classification of drugs is most likely to lead to tardive dyskinesia? a. SSRI b. Atypical antipsychotic c. Typical antipsychotic d. Anticonvulsant Answer: c. Typical antipsychotics are mostly linked to tardive dyskinesia. The other drugs would less commonly cause these types of symptoms. 2. What is the least likely acute symptom from starting or increasing the dose of an antipsychotic drug? a. Dystonia b. Tardive dyskinesia c. Neuroleptic malignant syndrome d. Akathisia Answer: b. Each of these are acute symptoms except for tardive dyskinesia, which is a late finding. 3. How long should a psychotropic drug be taken before tardive dyskinesia can occur? a. Two weeks b. One month c. Three months d. One year Answer: c. It takes a minimum of three months of taking the drug before tardive dyskinesia develops.

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4. Oral-buccal-lingual movements after being on a drug is referred to as what? a. Dystonia b. Akathisia c. Chorea d. Tardive dyskinesia Answer: d. These movements are referred to as tardive dyskinesia; these are exclusively movements related to the mouth and/or face. 5. How long after starting a typical antipsychotic (DRBD) will dystonia most likely occur? a. 24 hours b. 2-5 days c. 2 weeks d. 3 months Answer: b. Dystonia is relatively acute, accounting for symptoms that occur about 2 to 5 days after the starting of a DRBD. 6. What is least likely to be a symptom of drug-induced parkinsonism? a. Muscle rigidity b. Resting tremor c. Oral movements d. Postural instability Answer: c. Oral movements are least likely to be involved in drug-induced parkinsonism.

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7. Which movement disorder does not have an idiopathic counterpart? a. Dystonia b. Akathisia c. Myoclonus d. Oral-buccal movements Answer: b. Akathisia does not have an idiopathic counterpart but only occurs within the context of a drug-induced state. 8. Which is the most life-threatening response to taking a neuroleptic drug? a. Akathisia b. Acute dystonia c. Neuroleptic malignant syndrome d. Myoclonus Answer: c. Neuroleptic malignant syndrome is a life-threatening response to taking a neuroleptic drug. It involves fever and rigidity, along with other movement problems. 9. What percent of children taking antipsychotics for a minimum of six months will develop tardive dyskinesia? a. 9 percent b. 19 percent c. 39 percent d. 69 percent Answer: a. Children on neuroleptic drugs will have a 9 percent incidence of tardive dyskinesia after six months of use.

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10. Which drug is least likely to cause a movement disorder? a. Amphetamines b. Typical antipsychotics c. Antidepressants d. Anticonvulsants Answer: d. Each of these can cause a drug-induced movement disorder except for anticonvulsant drugs, which would rarely be involved.

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SUMMARY This course attempted to unlock some of the rigidity and diagnostic criteria seen in the Diagnostic and Statistical Manual, Fifth Edition or “DSM-V.” The DSM-V is a lengthy manual that reads like a dictionary of mental health terms, designed to make the abstract concepts of mental illness and categorize them. This is partly so that mental health workers can understand what the patient is suffering from in specific ways and partly to satisfy insurance and regulatory issues. What you have learned is that there is a great deal of information contained within the DSM-V volume about mental disorders. There are around a hundred different categorized mental disorders in the DSM-V. Several of them state “other specified” mental health disorders that were covered as much as possible in this course. They usually involve a combination of some of the other mental disorders but don’t fit neatly in any one category. There were other “unspecified” mental health disorders, which were not greatly covered in this course. These can mean just about anything that broadly fits into one of the larger categories or represent “catchall” categories that are difficult to clearly discuss. All other specified mental illnesses were covered in the chapters of this course. The subject of chapter one was neurodevelopmental disorders. These are usually diagnosed in childhood and can be diagnosed in infancy. They involve things like the various intellectual disabilities, communication disorders such as stuttering or language delays, autism spectrum disorders, ADHD, learning disorders and movement disorders (such as tics). While these are widely differing disorders, they are associated with some abnormality in a child’s neural circuitry. Chapter two focused on psychotic disorders and those disorders that resemble schizophrenia. They range from the very short duration of brief psychotic disorder to the lifelong personality 307

disorder called schizotypal personality disorder. Each of these will have characteristic psychotic features as a main component of the disorder but will differ in overall symptomatology and length of the illness. Chapter three covered disorders that fall under the umbrella-term of “bipolar disorders.” These are related mood disorders that are characterized by extreme fluctuations in mood. By definition, these patients will have at least one manic episode as seen by an elevation in mood. Some patients will have a reduction in mood when not truly manic. A select few will have rapid-cycling disease with frequent fluctuations in mood. Chapter four examined the different depressive disorders. It primarily included major depressive disorder and dysthymia but also included less commonly seen disorders, such as premenstrual dysphoric disorder and disruptive mood dysregulation disorder. As with many psychiatric classifications within the DSM-V, there was discussion of substance or medicationinduced depressive disorder and depression due to a medical condition. Anxiety disorders were the topic of chapter five. There are many mental illnesses that fall under this category. Some primarily affect children, such as separation anxiety. Some are very specific, such as specific phobia, agoraphobia, and social anxiety disorder. Others have no obvious focus, including panic disorder and generalized anxiety disorder. These and anxiety disorders that are due to substances and medical conditions were covered in detail in this chapter. Chapter six in the course involved a study of obsessive-compulsive disorder (OCD) and related disorders. The related disorders have a wide range of symptoms and causes. They include things like body dysmorphic disorder, hoarding disorder, excoriation disorder, and trichotillomania. There are categories for OCD that is related to substance use and to a medical condition, which were briefly covered. Chapter seven focused on the phenomenon of trauma and stressor-related disorders. The most well-known example is post-traumatic stress disorder; however, there are many other trauma and stress-related disorders that affect children and adults. These include reactive attachment 308

disorder, disinhibited social engagement disorder, acute stress disorder, and adjustment disorders. There is also a category called other specified trauma and stressor-related disorder, which includes any disorder that has mixed features that don’t fit into any other specific category. Dissociative disorders were the topic of chapter eight in the course. These are unique disorders that sometimes have their basis in trauma but can be stress-induced. The DSM-V has listed four different dissociative disorders. The most well-known is dissociative identity disorder, formerly known as “multiple personality disorder.” Other dissociative disorders include dissociative amnesia, depersonalization/derealization disorder, and other specified dissociative disorder, which carries features of several of the other known dissociative disorders. The topic of chapter nine was the different somatic disorders, beginning with somatic symptom disorder. There are several different somatic disorders with psychological origins or features that are recognized by the DSM-V as distinct entities. These include things like illness anxiety disorder, conversion disorder, and factitious disorder. There is a category for “psychological factors affecting other medical conditions,” which involves the different psychological states that influence the outcome of physical disorders. The major topic of chapter ten was feeding and eating disorders. The DSM-V sought this new category and included disorders like rumination disorder and pica in order to have an improved method of evaluating and treating eating-related disorders. The typical eating disorders, anorexia nervosa, bulimia, and binge-eating disorders remain as part of this classification. A newer sub-classification of other specified feeding and eating disorder has been added to identify individuals who do not fit neatly in any other category. The focus of chapter eleven in the course was elimination disorders. The DSM-V recognizes only three elimination disorders, including enuresis, encopresis, and other specified elimination disorder. These tend to occur in children but are possible in older people as well, especially if they have developmental disabilities. There can be physical, neurological, and psychiatric reasons behind having an elimination disorder, which were discussed in this chapter.

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Sleep-wake disorders were discussed in chapter twelve. They included a variety of sleeprelated medical and psychological disorders. The most common disorder is insomnia disorder; however, there are people with hypersomnolence disorder, narcolepsy, and breathing-related sleep disorders like sleep apnea. There are a number of disorders classified as parasomnias, including nightmare disorder, sleep terrors, and sleepwalking. Restless legs syndrome is also listed in the DSM-V as a sleep-wake disorder. Chapter thirteen was about sexual disorders, which included those related to otherwise normal human sexuality. Men may have erectile disorder, delayed ejaculation, hypoactive sexual desire disorder, and premature ejaculation, while women can have female orgasmic disorder, female arousal disorder, and genito-pelvic pain/penetration disorder. Both men and women can have gender dysphoria or sexual dysfunction related to the use of a substance or substances. The main topic of chapter fourteen in the course was disruptive, impulse control, and conduct disorders, which can affect children, adolescents, and adults. These include oppositional defiant disorder, intermittent explosive disorder, conduct disorder, and antisocial personality disorder. Also mentioned in this classification of DSM-V disorders were pyromania and kleptomania. The DSM-V includes a special category for other specified disruptive, impulse control, and conduct disorders. Chapter fifteen was about the DSM-V category of substance abuse and related disorders. It included a variety of substances of abuse and their complications. Each has unique features that separate it from other substance abuse disorders and has different types of people at risk for the disorder. In addition, gambling disorder was included as a “related disorder” as it shares similar features to substance use disorders. Chapter sixteen covered neurocognitive disorders, such as delirium and dementia. Both of these can cause mild, moderate, or severe cognitive deficits, which can be transient (as in delirium) or lifelong (as in most types of dementia). The DSM-V recognizes there are major neurocognitive disorders and mild neurocognitive disorders. There are different diagnoses for

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major or mild neurocognitive disorders with multiple different etiologies listed by the DSM-V, which were covered in the chapter. The topic of chapter seventeen was personality disorders. These are mental disorders defined as having a rigid and enduring pattern of thinking, behaving, and functioning that is considered out of the norm and that causes difficulty with the patient’s levels of functioning in work, school, relationships, and social activities. The individual is so tuned into their behavior and thinking that they often blame others for their difficulties and don’t recognize themselves as having a disorder. The symptoms often begin in the teens or in early adulthood. There are three major clusters of personality disorders. Chapter eighteen involved a discussion of paraphilias or paraphilic disorders. These are a collection of related disorders that involve sexual deviancy. Individuals with a paraphilic disorder have a specific urge to engage in sexually-related behaviors that are considered out of the norm for modern society. They include things like voyeurism, transvestism, fetishism, frotteuristic disorder, and both sexual sadism and sexual masochism. People with these disorders are intensely aroused by things that most people are not aroused by. The subject of chapter nineteen in the course was added to the DSM-V because of the relatively high prevalence of movement disorders as a result of a wide variety of drugs that can cause medication-induced movement disorders. The classic drug classification considered causative of most movement disorders is that of dopamine blockers used in the treatment of psychotic disorders. There is medication-induced akathisia and medication-induced acute dystonia, which come from using these medications.

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COURSE QUESTIONS AND ANSWERS 1.

What is meant by having an impairment in discourse in those who have language disorder? a. An inability to form words b. An inability to carry on conversation c. An inability to make words in sign language d. An inability to understand the written word Answer: b. The term “discourse” refers to a person’s ability to carry on a conversation with others. This can be from speech production, an inability to speak clearly or understand language.

Which DSM-V diagnosis used to be called phonological disorder? a. Childhood-onset fluency disorder b. Social communication disorder c. Speech sound disorder d. Language disorder Answer: c. The DSM-IV lists phonological disorder, which has since been renamed “speech sound disorder.”

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Which language-related disorder includes the phenomenon of the “lisp”? a. Speech sound disorder b. Language disorder c. Social (pragmatic) communication disorder d. Childhood-onset fluency disorder Answer: a. Speech sound disorder includes children who may lisp, which affects the intelligibility of their speech.

Which is not considered part of the inattention seen in ADHD? a. Easily forgets things b. Avoids tasks that have a lot of sustained mental effort c. Frequently fidgets or squirms in their seat d. Makes careless mistakes at school or work Answer: c. The frequent fidgeting and squirming are part of the hyperactivity seen in ADHD, while the others are part of inattention.

How long must the symptoms be present in order to have a diagnosis of ADHD? a. 2 months b. 6 months c. 1 year d. 2 years Answer: b. The symptoms of ADHD must be present for a minimum of six months to qualify for the diagnosis of the disorder.

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A child has difficulty in mathematic calculations and math problems. What is this called? a. Dyscalculia b. Dyslexia c. Dysgraphia d. Auditory processing disorder Answer: a. Dyscalculia involves problems doing and understanding math calculations. Dyslexia involves reading; dysgraphia involves writing; and auditory processing disorder involves listening.

Mimicking the movement of others involves what type of tic? a. Simple motor tic b. Complex motor tic c. Simple vocal tic d. Complex vocal tic Answer: b. This involves a complex motor tick and involves more than simple shrugging or blinking seen in simple motor tics.

What is the maximum time a person can have tics to qualify for transient tic disorder? a. 3 months b. 6 months c. 1 year d. 2 years Answer: c. The patient is said to have transient tic disorder if they have tics (vocal or motor) that last less than one year.

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Which is not considered a common tic in Tourette syndrome? a. Throat clearing b. Eye blinking c. Sniffing d. Coprolalia Answer: d. While coprolalia is one of the best-known features of TS, it is seen only 10 percent of the time.

10.

What is the inheritance status of Tourette syndrome? a. Autosomal dominant b. Autosomal recessive c. X-linked recessive d. Polygenic Answer: a. This is an autosomal dominant, monogenic disease with incomplete penetrance.

11.

What is not a typical feature of a delusion seen in delusional disorder? a. Incorrigibility (unchanging position despite evidence) b. Falsity (untruth of the delusional thought) c. Hostility (paranoid thinking regarding the delusion) d. Certainty (a strongly held position) Answer: c. The delusion can be about anything and does not have to be paranoid in nature.

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12.

Which type of delusion in delusional disorder is most closely linked to mood disorders? a. Delusions of self-accusation b. Sexual delusions c. Delusions of persecution d. Somatic delusions Answer: d. Somatic or body-related delusions are more closely linked to mood disorders than other types of delusions.

13.

Which type of delusion is most closely linked to having a diagnosis of schizophrenia? a. Delusions of self-accusation b. Sexual delusions c. Delusions of persecution d. Somatic delusions Answer: c. Delusions of grandeur and delusions of persecution are commonly seen in schizophrenia and other psychotic disorders.

14.

What is the major risk factor for brief psychotic disorder? a. Borderline personality disorder b. Sympathomimetic drug use c. Trauma d. Paranoid personality disorder Answer: c. The most common and major risk factor for brief psychotic disorder is a recent history of trauma, which acts as an overwhelming stressor for the patient.

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15.

What is the longest duration of symptoms in a patient with schizophreniform disorder? a. 2 weeks b. 6 months c. 1 year d. 2 years Answer: b. According to the definition of schizophreniform disorder, symptoms can last only six months or less.

16.

What is the major difference between schizophreniform disorder and schizophrenia? a. With schizophreniform disorder, there is no disordered speech. b. There are more delusions in schizophreniform disorder. c. There can be catatonia with schizophrenia but not with schizophreniform disorder. d. There are no differences in the symptoms seen in these two disorders. Answer: d. There are no differences in the symptoms seen in both of these disorders; the only difference is in the length of the symptoms.

17.

What are considered the main features seen in schizoaffective disorder? a. Apathy and delusions b. Depression and mania c. Hallucinations and depression d. Psychosis and mania Answer: d. The two main features of schizoaffective disorder include psychosis and mania, although other symptomatology can exist.

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18.

What is the major risk factor for substance and medication-induced psychotic disorder? a. Having a prior mental illness b. Being elderly c. Using stimulant drugs d. Using an addictive substance Answer: a. Having a prior mental illness predisposes a person to having a medication-induced or substance-induced psychotic disorder.

19.

What is considered a major feature of substance and medication-induced psychotic disorder? a. Catatonia b. Aggression c. Visual hallucinations d. Mood swings Answer: c. Both hallucinations and delusions are common features of this disorder and either one must be present to make the diagnosis according to the DSM-V.

20.

When evaluating a person who has possible psychotic disorder due to a medical condition, what is one disorder that doesn’t have to be ruled out? a. Delirium b. Temporal lobe epilepsy c. Drug withdrawal d. ICU psychosis

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Answer: b. These disorders must be ruled out to make the diagnosis of psychotic disorder due to a medical condition except for temporal lobe epilepsy, which can be a causative factor in this disorder. 21.

According to the DSM-V criteria for bipolar I disorder, how long must true mania last to qualify as having the disorder? a. At least one episode lasting a minimum of one week b. A true manic episode is not necessary as long as hypomania exists c. A two-week history of a sustained mania d. A four-week history of intermittent mania and hypomania Answer: a. There needs to be at least a week-long episode of true mania to make the diagnosis.

22.

How long must the depressive aspect of bipolar I disorder last to make the diagnosis according to the DSM-V? a. Two weeks b. Six months c. There does not have to be any length of time involving depression d. One day Answer: c. While depression can occur and may be brief in bipolar I disorder, there does not have to be any length of time involved with low mood.

23.

The patient is said to have “mixed features” with bipolar I disorder. What is the greatest risk when having an episode of this? a. Severe psychosis b. Suicide attempts c. Sleep deprivation d. Inability to medicate both mania and depression at the same time

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Answer: b. These patients are at a markedly increased risk of having completed suicide attempts from a combination of mania and depressive symptoms. 24.

What is not a key difference between hypomania and mania? a. The degree of social and occupational functioning is worse in mania. b. Hypomanic patients rarely need hospitalization. c. Hypomania is not associated with psychosis d. Hypomania is more likely to transform into a depressive episode than mania. Answer: d. Each of these is a key difference between hypomania and mania; however, both can transform into a depressive episode when not in an elevated mood state.

25.

How long must hypomania be present when making the diagnosis of bipolar II disorder? a. One day b. Four days c. One week d. Two weeks Answer: b. The symptoms of hypomania must be present for most of the day for four consecutive days to be called hypomania.

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26.

What is not one of the criteria for bipolar II disorder? a. Racing thoughts b. Distractibility c. Delusions d. Increase in high-risk behaviors Answer: c. As there is no psychosis in bipolar II disorder, delusions are not a part of the cyclothymia seen in bipolar II disorder.

27.

What is the only specifier for cyclothymic disorder? a. Occurring in childhood b. With anxious distress c. With psychotic features d. With prominence of hypomania Answer: b. The only specifier for cyclothymic disorder is “with anxious distress” to define those who have features of anxiety.

28.

What is not a common comorbidity with cyclothymic disorder? a. Brief psychotic disorder b. Sleep disorders c. Substance abuse d. ADHD Answer: a. Each of these is comorbid with cyclothymia although ADHD is usually comorbid in children and adolescents with the disorder. Brief psychotic disorder is not one of the commonly seen comorbidities.

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29.

What needs to be ruled out specifically to make the diagnosis of substance or medication-induced bipolar disorder? a. Temporal lobe epilepsy b. Cerebrovascular accident c. Agitation from dementia d. Delirium Answer: d. Delirium can come from substance use or the withdrawal of a substance that can mimic those seen in bipolar reactions to certain drugs and must be ruled out.

30.

There are manic symptoms that can be linked to substance or medicationinduced bipolar disorder. What is not considered one of these symptoms? a. Marked decrease in sleep b. Delusions c. Extreme talkativeness d. Poor concentration/distractibility Answer: b. Each of these is a potential symptom of substance or medicationinduced mania except for delusions, which are not a part of this disorder.

31.

What is the most effective therapy for children with disruptive mood dysregulation disorder? a. Family therapy b. SSRIs c. Atypical antipsychotics d. Individual psychotherapy Answer: a. As these kids have little insight regarding their disorder, individual therapy does not work. Drugs can facilitate therapy but are not preferred.

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Family therapy helps families learn to cope with and guide the affected child’s behavior. 32.

How long do the symptoms of major depressive disorder need to last to make the diagnosis? a. One week b. Two weeks c. One month d. Three months Answer: b. The collection of symptoms must last for two weeks straight in order to make the diagnosis of major depressive disorder.

33.

What is considered one of the must-have symptoms of major depressive disorder in making the diagnosis? a. Changes in sleep behaviors b. Thoughts of death or suicide c. Guilty or worthless feelings d. Loss of interest in previously enjoyed activities Answer: d. A low mood or loss of interest in previously enjoyed activities must be present as one of the major symptoms seen in the disorder.

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34.

What is involved in the diagnosis of double depression? a. Two episodes of major depressive disorder within a year b. The presence of dysthymia and major depressive disorder together c. The presence of mania or hypomania with dysthymia d. Having more severe dysthymia than most people Answer: b. The presence of dysthymia and major depressive disorder together constitutes “double depression.”

35.

What is the prominent feature of persistent depressive disorder? a. Sleep disturbance b. Appetite changes c. Low self-esteem d. Thoughts of death Answer: c. Patients with PDD or dysthymia have a prominence of cognitive symptoms, such as low self-esteem and fewer physical symptoms. Thoughts of death are not in the criteria for PDD.

36.

Which psychotherapeutic technique seems to work the best for patients with dysthymia? a. Interpersonal therapy b. Behavioral therapy c. Family-centered therapy d. Cognitive behavioral therapy Answer: a. Interpersonal therapy has the best efficacy among the different therapies for patients with PDD or dysthymia.

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37.

Which is not a somatic complaint seen in premenstrual dysphoric disorder? a. Pruritis b. Bloating c. Headache d. Breast tenderness Answer: a. Each of these is a common somatic symptom see in premenstrual dysphoric disorder, except for pruritis, which is not commonly seen.

38.

Which is not one of the major comorbidities that go along with substance or medication-induced depressive disorder? a. Bipolar disorder b. Major depressive disorder c. Dysthymia d. Generalized anxiety disorder Answer: d. There are several common comorbidities with substance or medication-induced depression, including all those listed except for generalized anxiety disorder.

39.

Which prescription drug is least likely to be linked to depression? a. Beta blockers b. ACE inhibitors c. Birth control pills d. Anticonvulsants Answer: b. ACE inhibitors are least likely to cause depression; however, the others are commonly linked to depressive symptoms in susceptible individuals.

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40.

Why is depression difficult to diagnose in Huntington’s disease? a. The patient has mixed features with make it hard to diagnose b. The depressive disease is often very subtle c. The depression predates the onset of obvious motor symptoms d. The depression is complicated by dementia which makes it difficult to diagnose Answer: c. The depression predates the onset of motor symptoms so it appears to be simple depression until the motor symptoms appear.

41.

What is not considered a related symptom seen in selective mutism? a. Aggressive outbursts b. Clinginess c. Social isolation d. Shyness Answer: a. The patient display clinginess, social isolation, and shyness. They also may have temper tantrums but rarely have outbursts of aggression.

42.

How long should symptoms of selective mutism last before making the diagnosis in a child? a. 2 weeks b. 1 month c. 3 months d. 6 months Answer: b. The symptoms must last for a minimum of one month before the diagnosis of selective mutism can be made.

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43.

Which drug is most helpful for the treatment of selective mutism? a. Lithium b. Anticonvulsant drugs c. SSRIs d. Benzodiazepines Answer: c. SSRI’s will address the anxiety that will treat the underlying factor in children who have selective mutism.

44.

The median age of onset of social anxiety disorder is what? a. 5 years b. 13 years c. 18 years d. 25 years Answer: b. The median age at onset is 13 years, commonly starting between 8 and 15 years of age.

45.

A patient has social anxiety disorder. What is not a common comorbidity with this disorder? a. Other anxiety disorders b. Depressive disorders c. Dissociative disorders d. Substance abuse disorders Answer: c. Each of these is a comorbidity with social anxiety disorder except for dissociative disorders, which would be less common.

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46.

What is the main feature of panic disorder? a. Chest pain b. Fear of medical illness c. Social isolation d. Recurrent unexpected attacks Answer: d. The main feature of panic disorder is the presence of recurrent, unexpected and unpredictable attacks. The other features are common but do not necessary to make the diagnosis.

47.

Which disorder most resembles generalized anxiety disorder? a. Major depression b. Bipolar disorder c. Substance abuse disorder d. Panic disorder Answer: a. There are a lot of similarities between major depression and GAD—so much so that it has been proposed to reclassify GAD as a mood disorder.

48.

Which classification of drugs is most commonly used for generalized anxiety disorder? a. Anxiolytics b. Mood stabilizers c. Atypical antipsychotics d. SSRIs Answer: d. SSRIs are not addictive and are good treatments for GAD. Anxiolytics are also used but are addictive so they are used for brief periods of time.

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49.

Agoraphobia is classically felt to be a fear of what? a. Public speaking b. Open spaces c. Enclosed spaces d. Animals Answer: b. While agoraphobia is disabling and involves a great many things, it is primarily a fear of open spaces.

50.

All of the criteria for agoraphobia must be met in order to make the diagnosis, including having symptoms for a minimum of how long? a. 1 month b. 3 months c. 6 months d. 1 year Answer: c. The symptoms must be present and ongoing for six months to make the diagnosis of agoraphobia.

51.

What is the difference between body dysmorphic disorder and the body distortion seen in eating disorders? a. The population tends to be younger with eating disorder-related body distortion. b. The perception of a body flaw is more out of proportion to reality in BDD. c. Patients with BDD have psychotic thinking around their body flaw, which is not the case with body distortion in eating disorders. d. Patients with BDD have a specific body area that is distorted, while eating disorders are concerned with body mass.

330

Answer: d. The main difference between the two is that BDD patients are concerned with a specific body area, while eating disorders are concerned with body mass. 52.

Body dysmorphic disorder is a discrete disorder that the DSM-V classifies as what type of disorder? a. Depressive b. OCD-related c. Anxiety-related d. Eating disorder-related Answer: b. Body dysmorphic disorder has been classified as an OCD-related disorder as it carries some features of this umbrella disorder.

53.

What is the prevalence of body dysmorphic disorder in the US in males? a. Less than one percent b. One percent c. 2.5 percent d. 7 percent Answer: c. The prevalence of BDD is higher in males than in females, with a prevalence of 2.5 percent in males and 2.2 percent in females. The average age at onset is about 16 years of age.

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54.

What associated problem do patients with hoarding disorder have? a. Kleptomania b. Bipolar disorder c. Major depressive disorder d. Excessive shopping Answer: d. About 80-90 percent of these patients have difficulty with excessive shopping.

55.

Hoarding disorder patients who have a compulsion to hoard bizarre things like feces, hair, and nails likely have what coexisting disorder? a. Obsessive-compulsive disorder b. Delusional disorder c. Schizotypal personality disorder d. Generalized anxiety disorder Answer: a. Patients who hoard bizarre things are likely under the 20 percent of patients who also have OCD.

56.

What is the ratio of males to females who have trichotillomania? a. 1:2 b. 1:4 c. 1:10 d. 1:20 Answer: c. There is a much higher incidence of trichotillomania in females, with a 1:10 ratio of males to females.

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57.

What is the medication classification of choice for trichotillomania? a. Mood stabilizers b. Atypical antipsychotics c. SSRIs d. Benzodiazepines Answer: c. SSRIs similar to those used in obsessive-compulsive disorder are the treatment of choice for people with trichotillomania.

58.

When does excoriation disorder usually first occur? a. At around 8-10 years of age b. At around 13-15 years of age c. At around 25-30 years of age d. After menopause Answer: b. The peak age at onset is around adolescence when acne first breaks out. A secondary peak occurs between 30 and 45 years of age.

59.

What is the main difference between excoriation disorder and true OCD? a. There are no obsessions in excoriation disorder b. Excoriation disorder has no distress or shame associated with the behavior c. OCD is less repetitive when compared to excoriation disorder d. The compulsions are stronger with excoriation disorder when compared to OCD Answer: a. With excoriation disorder (as with trichotillomania), there are no obsessions.

333

60.

Which disorder is least likely to be seen with excoriation disorder? a. Alcohol use disorder b. Obsessive-compulsive disorder c. Generalized anxiety disorder d. Prader-Willi syndrome Answer: c. Patients with each of these disorders have a close association to excoriation disorder with the exception of generalized anxiety disorder.

61.

What is not a symptom seen in a typical case of reactive attachment disorder? a. Blank facial expression b. Failure to respond in social exchanges c. Head banging d. Hypertonicity of the muscles Answer: c. Each of these is a symptom seen in RAD, however, head banging is not a part of the clinical criteria required to make the diagnosis.

62.

A child who has been institutionalized in infancy and hasn’t had a chance to attach consistently to any single adult is most likely to have what disorder? a. Disinhibited social engagement disorder b. Reactive attachment disorder c. Autism spectrum disorder d. Conduct disorder Answer: a. These children are high risk for disinhibited social engagement disorder, in which they attach to strangers indiscriminately because they haven’t attached to any consistent adult figure in their life.

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63.

Which is a requirement for the diagnosis of disinhibited social engagement disorder (DSED)? a. Malnutrition b. Background of severe neglect c. Developmental delays d. Aggression toward peers Answer: b. Regardless of the current symptomatology, the background of severe neglect must be a part of the diagnosis.

64.

Which is least likely to be a comorbid condition associated with PTSD? a. Anxiety disorders b. Major depression c. Bipolar disorder d. Substance use disorder Answer: c. Each of these is comorbid frequently with PTSD; however, bipolar disorder is generally organic and unrelated to a traumatic experience.

65.

Which cluster of symptoms in post-traumatic stress disorder does traumatic nightmares fall into? a. Alterations in arousal b. Re-experiencing the event c. Avoidance d. Negative alterations in cognition and mood Answer: b. Traumatic nightmares fall into the cluster of symptoms known as reexperiencing the event.

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66.

Which cluster of symptoms in post-traumatic stress disorder does selfdestructive behavior fall into? a. Alterations in arousal b. Re-experiencing the event c. Avoidance d. Negative alterations in cognition and mood Answer: a. Patients with alterations in arousal from PTSD will have reckless or self-destructive behavior as a result.

67.

What is the main symptom seen in acute stress disorder? a. Memory loss b. Emotional dysregulation c. Reckless behavior d. Intrusive memories Answer: d. While each of these things can be seen in acute stress disorder, intrusive memories are the primary symptoms seen.

68.

Which event is statistically more likely to lead to acute stress disorder? a. Sexual assault b. Being in a fire c. Being in a hurricane d. Car accident Answer: a. An extremely interpersonal assault or trauma has nearly a 50 percent ASD rate, while it is about 20 percent for the other traumatic events.

336

69.

Which symptom or symptoms best predict the development of PTSD after suffering from acute stress disorder? a. Reckless behavior b. Amnesia of the event c. Dissociative symptoms d. Depressive symptoms Answer: c. The presence of dissociative symptoms such as derealization, numbness, and depersonalization will best predict the development of PTSD after a traumatic event.

70.

Which is not a subclassification of adjustment disorder? a. Adjustment disorder with depressed mood b. Adjustment disorder with dissociation c. Adjustment disorder with anxiety d. Unspecified adjustment disorder Answer: b. Each of these is a type of adjustment disorder that varies with the patient’s symptoms; however, adjustment disorder with dissociation isn’t a known classification of this type of disorder.

71.

Which situation in the past medical and social history would most lead to a diagnosis of dissociative identity disorder? a. Childhood or adolescent bullying b. Childhood neglect c. Childhood sexual abuse d. Emotional abuse as a child Answer: c. The vast majority of patients with DID have a history of childhood sexual abuse.

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72.

At what age do most patients get diagnosed with dissociative identity disorder or DID? a. 4-6 years b. 8-12 years c. Adolescence d. 20-30 years Answer: d. While the disease is seen in young children, it is not diagnosed until the woman reaches 20-30 years of age. There is a preponderance of women with the disorder.

73.

At what age do alters first appear in dissociative identity disorder? a. 4-6 years b. 8-12 years c. Adolescence d. 20-30 years Answer: a. The first alters can first be diagnosed by around the age of 4-6 years of age and the number of alters increases as the individual grows up.

74.

What is the most common symptom seen in dissociative amnesia? a. The development of a new identity b. Travel away from home c. Flashbacks and nightmares d. Distress over lost memories Answer: d. A major feature of the disorder is distress over lost memories associated with a traumatic event. A new identity and travel away from home is linked to dissociative fugue state. Patients may or may not have nightmares and flashbacks.

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75.

What is the most common comorbid state with patients with dissociative amnesia? a. Major depression b. Specific phobia c. PTSD d. Dissociative identity disorder Answer: c. The patient with DA will often have PTSD as a comorbidity because the problem stems from experiencing a traumatic event.

76.

What is the major feature of derealization? a. Detachment from oneself b. Feeling as if in a dream c. Panic attacks d. Disorganized thinking Answer: b. The patient feels as if they are in a dream because they are detached from their environment but still feel relatively connected to their body.

77.

What is most likely in the history of a patient with derealization/depersonalization disorder. a. A family history of depression b. A sexual abuse history c. A history of childhood emotional abuse/neglect d. Parental separation as a baby Answer: c. A history of emotional abuse and neglect in childhood is the major historical background associated with depersonalization/derealization disorder.

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78.

Which is least likely to be a comorbidity with derealization/depersonalization disorder? a. Amnestic disorders b. Anxiety disorders c. PTSD d. Avoidant personality disorder Answer: a. Each of these is a common comorbidity with this disorder except for amnestic disorders.

79.

What is the least likely drug of choice used for people with depersonalization/derealization disorder? a. Fluoxetine b. Ziprasidone c. Clomipramine d. Naltrexone Answer: b. Each of these has been successfully tried in patients with this disorder; however, ziprasidone is an atypical antipsychotic, which is not generally used.

80.

What is the background most commonly seen in patients who’ve been suffering from dissociative trance states? a. Childhood deprivation b. Sexual assault c. Torture or captivity d. Emotional abuse

340

Answer: c. The symptoms seen in a dissociative trance involve someone who was severely abused, tortured, or in captivity for a long period of time. This makes it a relatively rare condition. 81.

What must be present if a physical disorder and somatic symptom disorder can coexist under the DSM-V? a. The symptoms must be unrelated to the physical disease. b. There must be the predominance of pain in the somatic symptoms. c. There can be no neurological symptoms involved in the somatic symptoms. d. The somatic symptoms must be disproportionate to the medical disorder’s typical symptoms. Answer: d. The patient’s response and somatic symptoms exceed that of the typical symptoms seen in the medical disorder.

82.

What is least likely to lead to somatic symptom disorder? a. Adolescent bullying b. Family breakups c. Childhood physical illnesses d. Sexual abuse Answer: a. This disorder has its roots in childhood, where stressful life events lead to the development of somatic symptoms that are disproportionate to actual physical illnesses.

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83.

Which is not true of illness anxiety disorder? a. The patient is hypervigilant about their health. b. The patient has no or few objective findings. c. The patient shows indifference to objective symptoms. d. Frequent checking for evidence of illness. Answer: c. The patient is often very anxious about any symptoms they have and fear that they have some type of serious illness or fatal disease.

84.

Which type of drug therapy has been found to be helpful in treating illness anxiety disorder? a. Mood stabilizers b. SSRIs c. Benzodiazepines d. Atypical antipsychotics Answer: b. SSRI drugs have been found to be effective in managing the symptoms of illness anxiety disorder. This disorder is similar to OCD, which also responds to SSRI drugs.

85.

What would be least likely to be seen as a manifestation of conversion disorder? a. Peripheral neuropathy b. Tremors c. Nausea/abdominal pain d. Seizures Answer: c. The key to conversion disorder is that the patient has some type of variable neurological symptoms. Abdominal symptoms generally do not have a neurological origin.

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86.

What is a predisposing factor to having an episode of conversion disorder? a. Severe psychological stress b. Prolonged neglect c. Natural disaster d. Physical illness Answer: a. Following severe psychological stress, a person dissociates and will develop neurological symptoms consistent with conversion disorder.

87.

What is the least likely underlying motive for factitious disorder? a. Disability leave b. To assume the patient role c. Fascination with the medical field d. Unresolved childhood trauma Answer: a. The patient with malingering will feign illness for disability leave or financial gain; however, the individual with factitious disorder may have any of the other listed motives.

88.

What is least likely to be a risk factor for pica? a. Sexual abuse b. Lack of nutrition c. Childhood neglect d. Lack of supervision Answer: a. Each of these is a risk factor for pica; however, childhood sexual abuse is less likely to be a risk factor.

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89.

What feature will exclude the diagnosis of rumination disorder? a. Being an adult b. Having episodic regurgitation c. Having the disorder for longer than a month d. Regurgitating in order to lose weight Answer: d. If the regurgitation or rumination is intended to lose weight, the diagnosis of rumination disorder is excluded and another specified feeding or eating disorder is the diagnosis.

90.

What is the prevalence of rumination disorder in the general population? a. 0.1 percent b. 1 percent c. 5 percent d. It is unknown Answer: d. Because of the embarrassment and reluctance to admit to the disorder, the actual prevalence of this disorder is not known.

91.

What is a common underlying cause for developing anorexia nervosa? a. Inability to cope with everyday stressors b. Body distortion and a desire to be thin c. Aversion to eating in public d. Aversion to certain foods because of taste, texture, or other features. Answer: b. These people have a strong desire to be thin and a distorted body image, making for a persistent goal to be thinner.

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92.

What is not one of the main factors or criteria in patients with anorexia nervosa? a. Body distortion b. Fear of gaining weight c. Being underweight for height d. Using laxatives Answer: d. Each of these is a critical factor in anorexia nervosa; however, using laxatives, while it can be a feature of the disease, isn’t one of the three main criteria.

93.

What is not a psychological factor in developing anorexia nervosa? a. Having ADHD in childhood b. Having OCD tendencies c. Poor stress management skills d. Having a phobia about being fat Answer: a. Each of these is a psychological factor in developing anorexia nervosa; however, having ADHD is not a psychological risk factor for the disorder.

94.

Which is not a diagnostic criterion for bulimia nervosa? a. Episodes of binge-eating and purging b. Use of vomiting, laxatives, and diuretics c. Inability to control eating behaviors d. Being underweight for height Answer: d. Each of these is a feature of bulimia nervosa (and is a diagnostic criterion) except for being underweight. Most patients with bulimia tend to be of a normal weight.

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95.

What is least likely to be a comorbidity along with bulimia nervosa? a. Generalized anxiety disorder b. PTSD c. Borderline personality disorder d. Alcoholism Answer: c. Each of these is a common comorbidity seen along with bulimia nervosa except for borderline personality disorder, which is not commonly seen.

96.

Which is not a new disorder in the DSM-V under the feeding and eating disorder category? a. Binge-eating disorder b. OSFED c. Rumination disorder d. Bulimia nervosa Answer: d. Each of these is a new disorder under the category of feeding and eating disorders except for bulimia nervosa, which has existed in previous manuals.

97.

What is the major feature seen in binge-eating disorder? a. Secretive overeating b. Obesity c. Periods of dieting d. Purging behaviors Answer: a. Secretive overeating is the main feature of binge-eating disorder. The patient’s weight can be anything from normal to obese. Dieting and purging are not features of this disorder.

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98.

What is not a common comorbidity with enuresis? a. ADHD b. OCD c. Depression d. Anxiety disorders Answer: b. The disorders listed are often comorbid with enuresis; however, OCD is not considered a common comorbid condition with this disorder.

99.

What is the minimum age at which enuresis can be diagnosed? a. 3 years b. 4 years c. 5 years d. 7 years Answer: c. The minimum age at which enuresis can be diagnosed is five years of age. It is developmentally within normal limits to have enuresis prior to this age.

100.

How long do the symptoms have to be present for enuresis to be diagnosed, according to the DSM-V? a. Three months b. Six months c. Nine months d. Twelve months Answer: a. The symptoms of enuresis must be present at least twice a week for three months in order to make the diagnosis.

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101.

There are four criteria that must be met to have encopresis. At what age must the child be at a minimum to diagnose the disorder? a. 4 years b. 5 years c. 7 years d. 9 years Answer: a. The child must be a minimum of four years old before the diagnosis can be made.

102.

Which is not a requirement for encopresis, according to the DSM-V? a. There is an age requirement b. There cannot be laxative or other substance use causing it c. The encopresis must be voluntary or intentional d. The disorder must last a minimum of three months Answer: c. The criteria stipulate that there has to be a frequent passage of feces but it can be either voluntary or involuntary.

103.

How often do episodes of encopresis need to occur in order to make the diagnosis? a. Three times a week b. Twice a week c. Once a week d. Once a month Answer: d. The individual must have encopresis episodes a minimum of once per month to make the diagnosis of this disorder.

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104.

Which classification of medications is first-line for sleep disorders like insomnia disorder? a. Hypnotics b. Benzodiazepines c. Tricyclic antidepressants d. Atypical antipsychotics Answer: a. Hypnotics are used to treat insomnia disorder as they are less addictive than benzodiazepines and tend to work better than atypical antipsychotics and tricyclic antidepressants, although all of these are used.

105.

What is considered the major feature of hypersomnolence disorder? a. Irritability b. Excessive daytime sleepiness c. Headaches d. Cognitive impairment Answer: b. Excessive daytime sleepiness is the major feature of hypersomnolence disorder, although the other symptoms may also be seen as part of the symptomatology.

106.

What is a first-line treatment for patients with hypersomnolence disorder? a. SSRIs b. Caffeine c. Nicotine d. Methamphetamines Answer: d. Amphetamines and methamphetamines will best treat the symptoms if the cause of the hypersomnolence is not determined to be a reversible thing.

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107.

What is not a feature of sleep-related hypoventilation? a. Elevated CO2 b. Low O2 c. Shallow breathing d. Snoring Answer: d. Patients with sleep-related hypoventilation will have shallow breathing and an elevated CO2 level with a low O2 level but will not snore. That is instead a feature of obstructive sleep apnea.

108.

In substance-related hypoventilation syndromes, which substance is least likely to be a contributing factor? a. Ethanol b. SSRI c. Opioid drugs d. Benzodiazepines Answer: b. The substance least likely to be a contributing factor in substancerelated hypoventilation is an SSRI drug.

109.

Which circadian sleep disorder most mimics narcolepsy? a. Jet lag b. Advanced sleep disorder c. Delayed sleep disorder d. Shift work disorder Answer: c. Patients with delayed sleep disorder have difficulty staying awake in the morning, similar to narcolepsy but it is because they rarely go to bed until 2 am or later and don’t get enough sleep if they awaken at the time most people wake up.

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110.

What sleep disorder can also be called “dream anxiety disorder”? a. Nightmare disorder b. Sleep terror disorder c. Somnambulism d. Circadian rhythm disorder Answer: a. Nightmare disorder is also referred to as “dream anxiety disorder.”

111.

What is the medication most used in the management of nightmare disorder? a. Trazodone b. Prazosin c. Topiramate d. Atypical antipsychotics Answer: b. The treatment of choice is prazosin; however, many other drugs have been employed, including the others listed.

112.

What is the major feature seen in REM-Sleep Behavior Disorder? a. Frequent unpleasant dreams b. Awakening in the morning without recollection of dreams c. Acting out dreams d. Lack of muscle tone during dreams Answer: c. The patient will act out their dreams, which may be injurious to themselves or their sleeping partner.

351

113.

What is the treatment of choice for REM-Sleep Behavior Disorder? a. Trazodone b. Atypical antipsychotics c. Gabapentin d. Clonazepam Answer: d. Patients have a 90 percent chance of resolution of their symptoms with clonazepam, which is the drug of choice for this condition.

114.

Which drug is most likely to contribute to delayed ejaculation? a. Benzodiazepines b. Beta blockers c. Phosphodiesterase 5 inhibitors d. SSRIs Answer: d. Delayed ejaculation is extremely common with SSRI drugs of all types.

115.

What is least likely to be a factor in erectile disorder? a. Inability to achieve an erection b. Soft erection c. Decreased libido d. Inability to maintain an erection Answer: c. Each of these can be a feature in men with erectile disorder; however, it generally does not affect libido.

116.

What is least likely to be a comorbidity with female orgasmic disorder? a. Bipolar disorder b. Depressive disorder c. Hypoarousal disorder

352

d. Anxiety disorder Answer: a. Each of these can be a comorbidity with female orgasmic disorder except for bipolar disorder, in which hypersexuality is more often seen. 117.

What is the most likely etiology of female sexual interest/arousal disorder? a. Physiology b. Psychological c. Hormonal d. Social Answer: b. While it can be multifactorial, it is most often seen as having a psychological origin. Even so, a complete history and a physical examination must be obtained.

118.

What mental or physiological issue must be screened for because of its high correlation with hypoactive sexual desire disorder? a. Sexual phobias b. Major depression c. Generalized anxiety disorder d. Hormonal deficiencies Answer: b. Major depression is commonly associated with hypoactive sexual desire disorder so this should be screened for in any male presenting with hypoarousal.

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119.

What medical intervention has the best success rate in treating men with male hypoactive sexual desire disorder? a. Testosterone b. SSRIs c. Phosphodiesterase 5 inhibitors d. Tricyclic antidepressants Answer: a. Testosterone deficiency is frequently a physical cause of this disorder so, after checking the level, replacement can improve libido in men with hypoarousal disorder.

120.

Which disorder is least likely to be comorbid with oppositional defiant disorder? a. ADHD b. Bipolar disorder c. Anxiety disorder d. Schizoid personality disorder Answer: d. These can be comorbid with ODD, except for schizoid personality disorder, which is not likely to be comorbid with this childhood disorder.

121.

What is the minimum allowable age for the diagnosis of intermittent explosive disorder? a. Two years b. Four years c. Six years d. Twelve years Answer: c. The minimum allowable age for the diagnosis of intermittent explosive disorder is six years of age. Below this age, the behavior could be developmental.

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122.

Which type of patient is least likely to have intermittent explosive disorder? a. A person with an anxiety disorder b. A person who has experienced physical trauma c. Former military personnel d. Morbidly obese patients Answer: a. Each of these individuals is at an increased risk of IED, except for those who have a coexisting anxiety disorder.

123.

About what percent of individuals with conduct disorder develop adult criminality? a. 10 percent b. 25 percent c. 50 percent d. 80 percent Answer: c. The rate of adult criminality in individuals with conduct disorder is about 50 percent.

124.

Which is least likely to be a comorbidity with conduct disorder? a. ADHD b. Bipolar disorder c. Substance abuse disorder d. Schizophrenia Answer: d. Each of these is a common comorbidity with conduct disorder except for schizophrenia, which is not usually associated with conduct disorder.

355

125.

Which drug is least likely to be effective in treating pyromania? a. SSRIs b. Benzodiazepines c. Mood stabilizers d. Opioid antagonists Answer: b. Each of these has successfully been used in the treatment of pyromania except for benzodiazepines, which are not typically used for this disorder.

126.

Which neurotransmitter pathway is least associated with kleptomania? a. Dopamine b. Serotonin c. Opioid d. GABA Answer: d. Each of these pathways appears to be involved in kleptomania except for the GABA pathway, which is not particularly involved.

127.

What is not a typical symptom of alcohol withdrawal? a. Tremors b. Hallucinations c. Muscle weakness d. Diaphoresis Answer: c. Each of these is a typical symptom of alcohol withdrawal except for muscle weakness, which is not typically seen.

356

128.

What is considered a first-line drug for the treatment of alcohol withdrawal symptomatology? a. Librium b. Phenytoin c. Carbamazepine d. Beta blockers Answer: a. Benzodiazepines like Librium are the first-line drugs used in the management of alcohol withdrawal disorder. The others can be used but are not considered to be first-line drugs.

129.

What is least likely to be a symptom of caffeine intoxication? a. Tachycardia b. Urinary retention c. Rambling speech d. Flushing Answer: b. All of these symptoms are common with caffeine intoxication but there tends to be urinary frequency and not urinary retention.

130.

What is the drug of choice used to manage many cases of acute cannabis intoxication? a. Lorazepam b. Atypical antipsychotics c. SSRIs d. Beta blockers Answer: a. The major thing that might have to be treated in cannabis intoxication is anxiety, which is often treated with lorazepam or another benzodiazepine.

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131.

How long must a person use cannabis to qualify as having cannabis use disorder? a. Three months b. Six months c. One year d. Two years Answer: c. The diagnosis is made after cannabis use has persisted for a year.

132.

What type of cancer is least associated with cannabis use disorder? a. Esophageal b. Oral c. Lung d. Bladder Answer: d. Cannabis use disorder is positively associated with each of these types of cancer but not to bladder cancer.

133.

What physical symptom is not seen with inhalant abuse? a. Peri-oral rash b. Rhabdomyolysis c. Cardiomyopathy d. Renal failure Answer: c. Cardiomyopathy is not seen with inhalant abuse; however, the other choices can be seen when an individual uses an inhalant.

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134.

What is not a typical symptom seen with benzodiazepine withdrawal? a. Hallucinations b. Seizures c. Psychomotor agitation d. Respiratory depression Answer: d. In fact, respiratory depression is seen with the overuse of the drug and not from benzodiazepine withdrawal. The other things are seen in this type of drug withdrawal.

135.

What is not a typical symptom of benzodiazepine use syndrome? a. Cravings for the drug b. Legal consequences of using the drug c. Using the drug in hazardous situations d. Unsuccessful attempts at stopping the drug Answer: b. The presence of legal consequences has been removed from this drug use syndrome as well as many substance abuse syndromes as it rarely happens.

136.

What is not a symptom of stimulant withdrawal syndrome? a. Tremor b. Hypersomnia c. Anhedonia d. Slow heartbeat Answer: a. Each of these can be seen with stimulant withdrawal syndrome except for tremor, which can be seen with use but not with withdrawal from the drug. The other things are seen with stimulant withdrawal.

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137.

What is the half-life of nicotine? a. 30 minutes b. Two hours c. Four hours d. Eight hours Answer: b. The half-life of nicotine is only two hours so smokers often smoke within this period of time to handle cravings.

138.

What is the most common comorbidity seen with tobacco use disorder? a. Major depression b. Anxiety disorder c. Other substance use disorder d. ADHD Answer: c. The most common comorbidity seen with tobacco use disorder is another substance use disorder.

139.

What is the one-year mortality rate in patients who have medically-caused delirium, according to the DSM-V? a. 10 percent b. 20 percent c. 40 percent d. 70 percent Answer: c. The mortality rate for medically-caused delirium is about 40 percent. It is much lower for patients with drug or medication-related delirium.

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140.

Which drug classification is most commonly used in the treatment of delirium? a. Antipsychotics b. Benzodiazepines c. Tricyclic antidepressants d. Anticonvulsants Answer: a. Both typical and atypical antipsychotic drugs are used to manage the symptoms seen in delirium.

141.

What is least likely to be an early finding in the development of a major neurocognitive disorder? a. Insomnia b. Mood swings c. Anxiety d. Delusions Answer: d. Delusions would indicate something else other than the development of a major neurocognitive disorder. The other findings are suspicious for a neurocognitive disorder.

142.

What is the most commonly seen underlying disorder in the major or mild neurocognitive disorders? a. Huntington’s disease b. Parkinson’s disease c. Vascular disease d. Alzheimer’s disease Answer: d. Alzheimer’s disease is the primary diagnosis underlying most cases of major or mild neurocognitive disorder.

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143.

Which neurotransmitter system is most defective in patients who have Alzheimer’s disease? a. Dopamine b. Serotonin c. Acetylcholine d. GABA Answer: c. Levels of acetylcholine decline in patients with Alzheimer’s disease for reasons that are not completely clear.

144.

What is the prevalence of Alzheimer’s dementia in people older than 80 years of age? a. 10 percent b. 25 percent c. 40 percent d. 60 percent Answer: b. About 25 percent of individuals older than 80 years will meet the diagnostic criteria for Alzheimer’s disease.

145.

The patient exhibits stepwise deficits in cognitive functioning over five or more years. What type of dementia is this most likely to be? a. Parkinson’s dementia b. Dementia with Lewy bodies c. Dementia from traumatic brain injury d. Vascular dementia Answer: d. As the dementia is from a series of small strokes, vascular dementia will present with stepwise decreases in functioning.

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146.

Patients with neurocognitive disorder secondary to traumatic brain injury will have abulia. What is this? a. Decreased ability to understand the spoken word. b. Rambling speech c. Lack of motivation d. Decreased understandability of speech Answer: c. Abulia represents lack of motivation, which can be obvious when attempting to engage the individual.

147.

Which drug of abuse is least likely to lead to a neurocognitive disorder? a. Marijuana b. Alcohol c. PCP d. Opioids Answer: a. Each of these has a known neurocognitive disorder affiliated with its use, even after stopping the drug except for marijuana.

148.

What percent of HIV-infected patients meet the criteria for mild neurocognitive disorder? a. 5 percent b. 25 percent c. 50 percent d. 75 percent Answer: b. While half will meet some criteria, about 25 percent will meet all the criteria for mild NCD secondary to HIV disease.

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149.

What is least likely to be seen as a feature of Creutzfeldt-Jakob disease? a. Myoclonus b. Memory impairment c. Hallucinations d. Aphasia Answer: d. Each of these can be seen in this rapidly progressive disease except aphasia is not commonly seen as a feature of this disorder.

150.

About what percent of Parkinson’s disease patients will have dementia? a. 10 percent b. 25 percent c. 50 percent d. 75 percent Answer: d. About 75 percent of patients diagnosed with Parkinson’s disease will have some degree of dementia.

151.

Which is least likely to be a comorbidity with paranoid personality disorder? a. Borderline personality disorder b. Substance use disorder c. Schizophrenia d. Agoraphobia Answer: c. Schizophrenia is not a typical comorbidity with PPD; however, other personality disorders, substance use disorder, major depressive disorder, and agoraphobia are often comorbid states with this.

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152.

Which personality disorder most involves an individual who chooses to be excluded from society? a. Narcissistic personality disorder b. Schizotypal personality disorder c. Paranoid personality disorder d. Schizoid personality disorder Answer: d. Individuals with schizoid personality disorder feel like they are bystanders in society and choose not to involve themselves with other people.

153.

Which personality disorder involves manipulating and exploiting others without remorse? a. Narcissistic personality disorder b. Avoidant personality disorder c. Borderline personality disorder d. Antisocial personality disorder Answer: d. Individuals with APD are cunning and manipulative; they use their intelligence to exploit others, often without remorse.

154.

Which personality disorder is primarily seen in women? a. Borderline personality disorder b. Avoidant personality disorder c. Schizoid personality disorder d. Antisocial personality disorder Answer: a. There is a strong predominance of women with borderline personality disorder, although it can rarely be seen in men.

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155.

Which type of personality disorder involves the continual need for attention from others? a. Avoidant personality disorder b. Borderline personality disorder c. Paranoid personality disorder d. Histrionic personality disorder Answer: d. Individuals with histrionic personality disorder have an inordinate need to gain the attention of others. They achieve this through their over-thetop behavior.

156.

Which other personality disorder is least likely to be comorbid with histrionic personality disorder? a. Avoidant PD b. Borderline PD c. Dependent PD d. Narcissistic PD Answer: a. Each of these personality disorders is likely to be comorbid with histrionic PD, except for avoidant PD, which is least likely to be seen with this disorder.

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157.

Which personality disorder involves extremes of shyness in adulthood? a. Dependent PD b. Avoidant PD c. Schizoid PD d. Borderline PD Answer: b. Patients with avoidant PD will be extremely shy and will have persistent feelings of inadequacy that interferes with social and interpersonal relationships.

158.

Which diagnosis does not represent a cluster C personality disorder? a. Borderline PD b. Obsessive-compulsive PD c. Avoidant PD d. Dependent PD Answer: a. Each of these except for borderline personality disorder is a cluster C disorder because there is a great deal of anxiety in the patient and internalization of distress.

159.

Which Axis I disorder is seen as a possible comorbidity in all cases of personality disorders? a. Substance use disorder b. Major depression c. Bipolar disorder d. PTSD Answer: a. Substance use disorder is a possible comorbidity in all cases of personality disorders as these people will use substances to cope with their problems.

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160.

What best differentiates people with obsessive-compulsive personality disorder and OCD? a. The need for sameness is less in OCD b. There are fewer true obsessions in the personality disorder c. There is a longer duration of disease in patients with OCPD d. There is a need for rules in OCPD but not in OCD Answer: b. There are fewer true obsessions in OCPD than there are in patients who have OCD.

161.

What category of mental illness is most closely related to the paraphilic disorders? a. Depressive disorders b. OCD c. Anxiety disorders d. Conduct disorders Answer: b. Paraphilias are strongly linked to OCD, making them medically treatable along those lines.

162.

What is a drug of choice in treating voyeuristic and exhibitionistic disorder? a. Benzodiazepines b. Atypical antipsychotics c. Mood stabilizers d. SSRIs Answer: d. SSRIs are a first-line treatment for these disorders in keeping with the idea that they are related to obsessive-compulsive disorder.

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163.

What is the most effective therapy for the resolution of exhibitionistic disorder? a. Cognitive behavioral therapy b. Family systems therapy c. Psychoanalytic therapy d. There is no treatment that will resolve this disorder Answer: d. This is considered a lifelong disorder that does not resolve with therapy or other treatment but can simply be managed.

164.

What is the DSM-V position on bondage between a dominant and submissive individual? a. This is not considered a sexual masochism or sadism disorder b. It is considered a sadism disorder but not a masochistic disorder c. It is considered a disorder if one person is under the age of 18 d. Both parties qualify as having a masochistic or sadistic disorder Answer: a. Bondage between two consenting adults is considered mild behavior that does not rise to the category of being a sadistic or masochistic disorder.

165.

What feature is a requirement in order to have sexual masochism disorder? a. They must engage in behavior with a consenting adult b. They must be nonconsenting themselves c. They must have significant distress because of the behavior d. They must be over 18 years of age Answer: c. As with all paraphilias, the patient must have significant distress because of the behavior in order to qualify as having sexual masochism disorder.

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166.

Which paraphilia requires the admission of sexual fantasies in order to make the diagnosis? a. Sexual sadism disorder b. Sexual masochism disorder c. Exhibitionistic disorder d. Voyeuristic disorder Answer: b. Only in sexual masochism does the diagnosis require the admission of sexual fantasies. In the others, the patient can deny the fantasies but will have behavior to suggest that they exist.

167.

At what time in a person’s life does fetishistic disorder begin? a. Childhood b. Puberty c. Late adolescence d. Early adulthood Answer: b. This disorder first develops at around the time of puberty but can occur earlier than that.

168.

What diagnosis is not likely considered in the differential diagnosis of fetishistic disorder? a. Exhibitionistic disorder b. Transvestic disorder c. Sexual masochism disorder d. Fetishistic tendencies Answer: a. Each of these needs to be ruled out as possibly mimicking fetishistic disorder except for exhibitionistic disorder, which is not similar.

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169.

What is the minimum amount of time the patient has to have symptoms in order to have the diagnosis of a paraphilic disorder? a. Two weeks b. One month c. Three months d. Six months Answer: d. Without exception, the symptoms of a paraphilic disorder must happen for six months in order to make the diagnosis.

170.

Which paraphilia is seen in a high proportion of gay males? a. Transvestic disorder b. Fetishistic disorder c. Pedophilic disorder d. Sexual masochism disorder Answer: b. About 25 percent of individuals with fetishistic disorder consider themselves to be gay males. The others mainly involve heterosexual males.

171.

Akathisia is an acute reaction to a psychotropic drug. What is the definition of akathisia? a. Motor restlessness b. Muscle rigidity c. Choreiform movements d. Increased reflexes Answer: a. Akathisia involves motor restlessness and pacing behaviors after starting or initiating a psychotropic drug.

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172.

What best describes twisting or abnormal posture of a body part after starting a dopamine receptor blocking drug? a. Dystonia b. Akathisia c. Chorea d. Tardive dyskinesia Answer: a. Dystonia best describes this type of movement disorder.

173.

What is the most common treatment for drug-induced parkinsonism? a. L-dopa b. Hydroxyzine c. Benztropine d. Drug withdrawal Answer: d. Withdrawal of the drug is the most common and most effective treatment for drug-induced parkinsonism.

174.

What is the incidence of drug-induced movement disorder after taking typical antipsychotics? a. 10 percent b. 40 percent c. 65 percent d. 90 percent Answer: b. The incidence of drug-related movement disorder after taking typical antipsychotics is about 40 percent (at an estimate of 42 percent).

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175.

Which movement disorder is the most difficult to treat by withdrawing the offending drug? a. Tardive dyskinesia b. Akathisia c. Tardive dystonia d. Neuroleptic malignant syndrome Answer: c. Of these, tardive dystonia is very difficult to treat and often persists after stopping the drug.

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374

DSM v Audio Crash Course - Complete Review of the Diagnostic & Statistical Manual of Mental Disorder

Articles inside

Pedophilic Disorder (302.2

Frotteuristic Disorder (302.89

Sexual Sadism Disorder (302.84

Exhibitionistic Disorder (302.4

Mild Neurocognitive Disorder (331.83

Schizoid Personality Disorder (301.20

Caffeine-Related Disorders

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

Antisocial Personality Disorder (301.7

Premature (Early) Ejaculation (302.75

Conduct Disorder (312.81

Restless Legs Syndrome (333.94

Nightmare Disorder (307.47

Sleep Terrors (307.46

Sleepwalking (307.46

Dissociative Amnesia (300.12

Encopresis (307.7

Psychological Factors Affecting Other Medical Conditions (316

Binge-Eating Disorder (307.51

Anorexia Nervosa (307.1

Body Dysmorphic Disorder (300.7

Specified Panic Attack

Autism Spectrum Disorder (299.0

Attention Deficit Hyperactivity Disorder (314.0X

Specific Learning Disorders (315

Persistent (Chronic) Motor or Vocal Tic Disorder

Schizophrenia (259.90

Speech Sound Disorder (previously Phonological Disorder or 315.39

Global Developmental Delay

Language Disorder