Psychiatric Disorders PDF

**Neurodevelopmental Disorders** Summary: - Often begin before school age - Causes impairments in personal, social, academic or occupational functioning - Deficits: vary from specific learning or executive functioning impairments to broader issues with social skills or intelligence...

**Neurodevelopmental Disorders** Summary: - Often begin before school age - Causes impairments in personal, social, academic or occupational functioning - Deficits: vary from specific learning or executive functioning impairments to broader issues with social skills or intelligence - Co-occurrence: common for multiple disorders to occur together (i.e: Autism, Intellectual Disability, ADHD and learning disorders) - Symptoms: Can include: - Deficits (social communication issues) - Excesses (repetitive behaviors and restrictive interests) **Intellectual Disability** - Timeline: during onset of developmental period - Characteristics: - Intellectual and adaptive functioning deficits in conceptual, social and practical domains - **Diagnostic Criteria** (All 3 must be met) 1. Deficits in intellectual functions: Impairments in reasoning, problem solving, and learning (confirmed through testing) 2. Adaptive deficits: Difficulty with daily activities without support 3. Onset: Deficits arise during the developmental period - *Specifiers are based on severity* - - **Mild** - **Moderate** - **Severe** - **Profound** - - **Associated Features Supporting Diagnosis** - Difficulties with social judgement, risk assessment, self-management of behavior/emotions/relationships/motivation in school or work - Lack of communication skills which can lead to disruptive and aggressive behaviors - Gullibility and lack of awareness - More susceptible to exploitation - Higher risk of suicide - **Global Developmental Delay** - \< 5 years old - Fails to meet expected developmental milestones in several areas of intellectual functioning - Requires reassessments after a certain period - **Unspecified Intellectual Disability (Intellectual Developmental Disability)** - \> 5 years old - Used when intellectual disability is difficult due to sensory pr physical impairments (blindness, deafness, or motor disabilities) or severe problems/mental disorders - Should only be used in exceptional circumstances and must be reassessed after some time **Communication Disorders** **Summary:** - Involve deficits in language, speech and communication - Assessment must consider cultural and language context - Diagnostic category includes: - **Language Disorder** - **Speech Sound Disorder Childhood** - **Onset Fluency Disorder** - **Social Communication Disorder** - **Unspecified Communication Disorders** **Diagnostic Criteria** - Persistent difficulties in acquiring and using language across different forms: - Reduced vocabulary - Limited sentence structure - Impaired discourse (connecting sentences and explaining topics) - Significantly below age expectations - Affects communication, social participation, academic achievement, work performance - Symptoms in early development are NOT due to sensory impairments, motor dysfunction, or other medical conditions, nor are they explained by intellectual disability or developmental delays **Types of Communication Disorders:** 1. ***Speech Sound Disorder*** a. Diagnostic Criteria i. Difficulty in speech sound production that interferes with speech intelligibility or prevents verbal communication of messages ii. Disturbance causes limitations in effective communication that interfere with social participation, academic achievement, or occupational performance iii. Onset of symptoms is in the early developmental period iv. Difficulties are not attributed to and congenital or acquired conditions (cerebral palsy, deafness, TBI, etc.) 2. ***Childhood Onset Fluency Disorder (Stutter)*** b. Diagnostic Criteria v. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual's age and language skills 1. Persist over time 2. Characterized by the frequent and marked occurrences of one or more of the following: a. Sound and syllable repetitions b. Sound prolongations of consonants and vowels c. Broken words d. Audible or silent blocking e. Circumlocutions (words substitutions to avoid problematic words) f. Words produced with an excess of physical tension g. Monosyllabic whole-word repetitions vi. Disturbance causes anxiety about speaking and limitations in communication, social participation, or academic/work performance vii. Symptoms begin in early development viii. Disturbance is not due to motor-speech or sensory deficits, neurological issues (Stroke) or other medical/mental conditions 3. ***Social (Pragmatic) Communication Disorder*** c. Diagnostic Criteria ix. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by: 3. Deficits in using communication for social purposes 4. Impaired ability to adjust communication based on listener needs 5. Difficulties following conversation rules x. Difficulties understanding implicit meanings (humor, sarcasm, metaphors, and context-dependent meanings) xi. Deficits cause functional limitations in communication, social participation, relationships, academics, or work xii. Symptoms begin in early development xiii. Symptoms are not due to medical/neurological conditions 4. ***Unspecified Communication Disorder*** d. **Summary:** xiv. When symptoms of a communication disorder cause significant distress or impairment but do not fully meet the criteria for any specific communication or neurodevelopmental disorder xv. It is used when the clinician chooses not to specify why criteria aren't met or when there is sufficient information for a more specific dx e. **Diagnostic Criteria** xvi. Persistent deficits in social communication interaction include: 6. Trouble with back-and-forth conversations, sharing feelings or interests or starting/responding to social interactions 7. Problems with body language, facial expressions, and understanding gestures 8. Difficulty making friends, adjusting behaviors in different situations, or showing interest in others xvii. Repetitive behaviors or interests include: 9. Repeating movements, actions, or words 10. Sticking to routines and getting upset with small changes 11. Overreacting or underreacting to sensory experiences xviii. Severity: based on how much social and repetitive behavior impacts daily life xix. Symptoms start early and can cause problems in social life, work or other important areas xx. These disturbances cannot be explained by other cognitive/mental/psychological disorders f. **Specifiers**: xxi. With/without intellectual impairment xxii. With/without language impairment xxiii. Associated with a known medical/genetic condition or environmental factor xxiv. Associated with another neurodevelopmental, mental or behavioral disorder xxv. With catatonia xxvi. Severity Levels: 12. Level 1: Requiring Support h. Noticeable social communication issues without support i. Difficulty initiating conversation and maintaining conversations j. Inflexible behaviors affect functioning in some areas 13. Level 2: Substantial Support k. Significant communication deficits even with support l. Limited social interaction and difficulty coping with change m. Behaviors often interfere with ADLs 14. Level 3: Very Substantial Support n. Severe communication and social interaction challenges o. Minimal response to others and difficulty handling change p. Restricted behaviors greatly impact daily life **Attention Deficit/Hyperactivity Disorder** **Diagnostic Criteria:** 1. **Inattention Symptoms** (*at least 6 for 6 months or 5 for ages 17 years and older*) that significantly affect social, academic, or work functioning and are not due to other causes like oppositional behavior or lack of understanding a. Careless mistakes in work or activities b. Difficulty sustaining attention in tasks or play c. Not listening when spoken directly d. Failure to follow through with tasks e. Difficulty organizing tasks and activities f. Avoidance of tasks requiring sustained mental effort g. Losing things needed for tasks h. Easily distracted by unrelated stimuli i. Forgetfulness 2. **Hyperactivity Symptoms** (*at least 6 for 6 months or 5 for ages 17 years and older*) j. Fidgeting or squirming k. Leaving seat when expected to remain seated l. Running or climbing in inappropriate situations m. Inability to play quietly or engage in leisure activities calmly n. Always "on-the-go" , as if driven by a motor o. Talking excessively p. Blurting out answers before questions are finished, constantly interrupting q. Difficulty waiting for turn r. Interrupting or intruding on others 3. Symptoms are present before 12 years old 4. Symptoms appear in at least 2 settings 5. Symptoms interfere with or reduce the quality of social, academic, work functioning 6. Symptoms are not better explained by another disorder **Specifiers:** - **Combined Presentation**: if criterion from both hyperactivity and inattentive are present within the last 6 months - **Predominantly Inattentive Presentation** - **Predominantly Hyperactive Presentation** - Specify if: - **In partial remission**: full criteria were previously met, but fewer than the full criteria are presently being met - Symptoms still cause impairment in academic, social and occupational functioning - Severity: - **Mild**: few symptoms beyond those required for diagnosis - **Moderate**: Symptoms or functional impairment are between mild and severe - **Severe**: many symptoms beyond those required for diagnosis, or several particularly severe symptoms - Symptoms result in marked impairment in social or occupational functioning **Treatment Options:** - **Cognitive Behavioral Therapy** - How CBT works - CBT helps people identify unhealthy thought patterns and behaviors  - It teaches people how to change those patterns into more positive ones  - CBT can help people deal with challenges in school, work, and relationships  - It can also help people address other mental health conditions  - Other types of therapy for ADHD - **Behavioral therapy:** Helps people change their behaviors, such as by providing practical support or emotional support  - **Mindfulness:** Helps people increase awareness and calmness through techniques like breathing exercises  - **Family therapy:** Helps loved ones learn how to cope with the stress of living with someone who has ADHD  - **Group therapy:** Involves multiple people receiving psychotherapy together  - **Parenting skills training:** Teaches parents how to use rewards and consequences to encourage behavior changes  - **EEG biofeedback:** A type of neurotherapy that measures brain waves and teaches people new focusing techniques  - **Medications** - ADHD medications increase brain chemicals like dopamine and norepinephrine. - These chemicals help improve: - Attention span - Reducing hyperactivity - Controlling impulsive behavior - Managing executive dysfunction - Most common ADHD medications **Tourette's Disorder** ***Diagnostic Criteria:*** - Both motor tics and at least one vocal tic have been present at some point, though not necessarily at the same time - Tics may wax and wane in frequency but have lasted for more than 1 year since the first tic appeared - Onset of tics before age of 18 - Tics are not due to substance use or other medical conditions **Schizophrenia Spectrum and other Psychotic Disorders** **Summary:** - These disorders include schizophrenia, other psychotic disorders, and schizotypal personality disorders - ***Characterized by abnormalities in one or more of the following five areas:*** - **Delusions** - Fixed false beliefs that are resistant to contrary evidence - Types of Delusions: - **Persecutory**: Belief of being harmed or harassed by others - **Referential**: belief that certain events or people are specifically directed at oneself - **Grandiose**: belief of exceptional abilities or importance - **Erotomanic**: belief that someone is in love with them - **Nihilistic**: belief that a disaster or catastrophe is imminent - **Somatic**: Focus on preoccupations with health or bodily fluids - **Bizarre Delusions**: Implausible beliefs (*aliens are speaking to you*) - **Non-Bizarre Delusions**: Could happen (*a gang is after you*) - **Hallucinations**: - Perception-like experiences without external stimuli, vivid and clear, not under voluntary control - Most common in auditory form, but can occur in other sensory modalities (visual, somatic, gustatory) - Hallucinations that occur while falling asleep (hypnagogic) or waking up (hypnopompic) - Hallucinations in cultural religious contexts may be considered normal - **Disorganized Thinking** (inferred from speech): - **Derailment or Loose Associations** -- jumping from topic to topic - **Tangentiality** -- answers to questions are unrelated - **Severe Incoherence or Word Salad** -- incomprehensible speech - These may be severe enough to impair effective communication - **Grossly Disorganized or Abnormal Motor Behaviour** - Childlike Silliness, unpredictable agitation, or difficulties with goal-directed behavior affecting ADLs - **Catatonia**: Marked decrease in environmental reactivity, including: - **Negativism**: resistance to instructions - Inappropriate or bizarre posture - **Mutism and Stupor**: lack of speech and movement - **Catatonic Excitement**: Stereotyped movements, staring, grimacing, and echolalia (meaningless repetition of words) - **Negative Symptoms** - These symptoms are less prominent in other psychotic disorders but are **significant in schizophrenia** - **Diminished Emotional Expression:** Reduced facial expressions, lack of eye contact, flat or monotone speech - **Avolition**: Decreased motivation for self-initiated activities, leading to inactivity - Other negative symptoms: - **Alogia**: reduced speech output (Poverty of Speech) - **Anhedonia**: decreased ability to experience pressure - **Associality**: lack of interest in social interactions which may overlap with avolition **Schizotypal (Personality) Disorder** **Delusional Disorder** - **Diagnostic Criteria:** - The presence of **one or more delusions** with a duration of **1 month or longer** - **Criterion A for Schizophrenia has never been met** - Hallucinations, if present are not prominent and are related to the delusional theme - Apart from the impact of the delusions, **functioning is not significantly impaired.** - The person's behaviour is not specifically bizarre or odd - **Brief** manic or depressive episodes - Exclusion of other mental, psychological, or medical causes - **Specifications**: - - Erotomanic Type - Grandiose Type - **Jealous Type**: central theme is that his or her lover is unfaithful - Persecutory Type - Somatic Type - Mixed Type - Unspecified Type - - With bizarre content: if the delusions are implausible **Brief Psychotic Disorder** - **Diagnostic Criteria** - Presence of **1 or more** of the following symptoms. ***At least one of these MUST be (1),(2), or (3)*** 1. Delusions 2. Hallucinations 3. Disorganized Speech 4. Grossly Disorganized or Catatonic Behaviour - **Duration of episode is at least 1 day but less than 1 month** with eventual return to premorbid functioning - The disturbance is not better explained by other psychological dxs **Schizophreniform Disorder** - **Diagnostic Criteria**: ***2 or more of the following, each present for a significant portion of time during a 1-month period***. At least one of these must be (1), (2), or (3) 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized 5. Negative Symptoms - Episode must last **at least 1 month but less than 6 months** - Schizoaffective and Mood Disorders must be ruled out - Exclusion of substance use or medical conditions **Schizophrenia** - **Diagnostic Criteria** - Must have ***2 or more for a significant portion of time during a 1-month period*** or less of treated) 1. Delusions 2. Hallucinations 3. Disorganized Speech 4. Grossly disorganized or catatonic behavior 5. Negative Symptoms - **Functional Impairment** - Significant decrease in functioning in one or more major areas since onset of symptoms - If onset is during childhood/adolescence, failure to achieve expected level of academic, occupational or social functioning - **Duration** - Symptoms persist for at least **6 months** - Must include **1 month of active phase symptoms** - May also include **prodromal or residual symptoms** - Exclusion of other disorders including substance use or medical diagnoses - **Key Features** - **Affective Symptoms:** - - Inappropriate affect - Dysphoric mood - Disturbed sleep patterns - Food-related issues - - **Perceptual and Cognitive Symptoms:** - Depersonalization and Derealization - Somatic Concerns - Cognitive Deficits - Impaired declarative memory, working memory, language functions and executive functions - Slower processing speed - Sensory processing abnormalities - Reduced attention and inhibitory capacity - Social cognition deficits: difficulty inferring others' intentions leading to delusional thinking - Insight impairment - **Behavioral and Emotional Symptoms** - Anxiety and phobias are common - Hostility and aggression especially in younger males with hx of abuse, violence, substance use, or treatment non-compliance) - Aggression (rare but may occur under certain conditions) - **Neurological and Cognitive Impairments** - Cognitive deficits lead to vocational and functional impairments - Neurological soft signs: impairments in motor coordination, sensory integration, and motor sequencing - Left-right confusion and disinhibition of associated movements - Key Notes: - Suicide Risk: Approx 5%-6% of individuals with schizophrenia die by suicide, 20% attempt suicide and many more have SI - People with schizophrenia have high comorbidity with substance use, especially tobacco use disorder - Increased rates of anxiety and OCD - Schizotypal and Paranoid personality disorder may precede the onset of schizophrenia - Reduced life expectancy due to medical conditions like: - - Weight Gain - Diabetes - Metabolic Syndrome - CV and Pulmonary Disease - - Poor health maintenance - Increase risks of chronic illness due to: - Poor lifestyle choices - Medications used in treatment - Cigarette smoking - Dietary habits **Treatment Options** - Medications: - Antipsychotic medications are the primary treatment for schizophrenia. - **These drugs mainly target brain receptors for neurotransmitters** like **dopamine** and **serotonin**, and new drugs like xanomeline and trospium chloride affect acetylcholine receptors. - The goal is to manage symptoms with the **lowest possible dose**. - Other medications, like **antidepressants**, **mood stabilizers**, or **antianxiety drugs**, may also be used. - It can take **several weeks to see improvements.** - Side effects are common, and psychiatrists monitor for these, sometimes ordering blood work. - Antipsychotics are classified into first-generation and second-generation, with the latter having fewer movement-related side effects like tardive dyskinesia (involuntary, repetitive movements). - **First Generation Medications:** - Chlorpromazine. - Fluphenazine. - Haloperidol (Haldol). - Perphenazine (Trilafon). - **Second Generation Medications:** - Aripiprazole (Abilify). - Asenapine (Saphris). - Brexpiprazole (Rexulti). - Cariprazine (Vraylar). - Clozapine (Clozaril. - Iloperidone (Fanapt). - Lumateperone (Caplyta). - Lurasidone (Latuda). - Olanzapine (Zyprexa). - Paliperidone (Invega). - Quetiapine (Seroquel). - Risperidone (Risperdal). - Xanomeline and trospium chloride (Cobenfy). - Ziprasidone (Geodon). - - Long Acting Injectable Antipsychotics - Some antipsychotics are available as long-acting shots, given in the muscle or under the skin administered every 2 to 4 weeks, but the frequency can vary. - These shots may be a good option for those who prefer fewer pills and can help people stay consistent with their treatment plans. - Common antipsychotic shots include: - Aripiprazole (Abilify Maintena, Abilify Asimtufii, Aristada) - Fluphenazine decanoate - Haloperidol decanoate - Paliperidone (Invega Sustenna, Invega Trinza, Invega Hafyera) - Risperidone (Risperdal Consta, Perseris, others) **Schizoaffective Disorder** - **Diagnostic Criteria** - **Major Mood Episode:** uninterrupted illness with major mood episode (major depressive or manic) occurring at the same time as schizophrenia symptoms - **Delusions/Hallucinations:** must be **present for 2 or more weeks without a major mood episode** during the lifetime of the illness - **Major Mood Symptoms:** must **be present for most of the active and residual phases** of the illness - Exclusion of substance use disorder or other medical conditions **Substance/Medication-Induced Psychotic Disorder** - **Diagnostic Criteria** a. Presence of one or both of: i. Delusions ii. Hallucinations b. There is evidence from the hx, physical assessment or lab findings of both (1) and (2) iii. The symptoms in Criterion A developed soon after substance intoxication or withdrawal or after exposure to a medication iv. The substances involved can produce the symptoms in Criterion A c. The disturbance is not better explained by another psychotic disorder d. The disturbance does not occur exclusively during an episode of delirium e. The disturbance causes significant distress in academic, social or occupational functioning **Bipolar I Disorder** - **Diagnostic Criteria: Hypomanic/Manic Episode** - **Mood and Energy Changes** - Distinct period of elevated, expansive, or irritable mood and increased activity or energy - **Duration**: at least 1 week (if hypomanic, at least 4 consecutive days) - **Symptoms:** - At least **3 symptoms** (4 if mood is irritable) must be present to a significant degree - **Inflated self-esteem or grandiosity** - **Decreased need for sleep** - **More talkative than usual** - **Flight of ideas** - **Distractibility** - **Increased goal-directed activity or psychomotor agitation** - **Excessive involvement in risky activities** - **Impairment or Psychotic Features** - Mood Disturbances must impair functioning significantly or require hospitalization - Psychotic features may be present - **Not substance use or Medical Dx Related** - **Diagnostic Criteria: Hypomanic Episode** a. Like above with the addition of: i. Changes must be observable by others b. **No marked impairment**- does not cause marked impairment in functioning or require hospitalization - **Diagnostic Criteria: Major Depressive Episode** a. **Symptoms**: **5 or more of the following during a 2-week period**, with at least one being depressed mood or loss of interest or pressure i. Depressed Mood ii. Loss of Interest/Pleasure iii. Significant Weight Change or Appetite Changes iv. Sleep Disturbances v. Psychomotor agitation or retardation vi. Fatigue or worthlessness or excessive guilt vii. Diminished ability to concentrate viii. Recurrent thoughts of death or suicidal ideation b. Symptoms cause significant distress and impair functioning c. Not due to substance use or other medical dxs **Bipolar II Disorder** A. **Diagnostic Criteria** a. Hypomanic Behaviors (See Bipolar I) b. Major Depressive Behaviors (See Bipolar I) B. Criteria met **from at least one hypomanic** episode and **one major depressive** episode C. Has never had a manic episode D. Exclusion of other physical or mental disorders E. Clinically significant distress or impairment in ADL functioning **Bipolar I vs Bipolar II** - **Manic Episodes:** - **Bipolar I**: Involves severe manic episodes lasting weeks. People can often continue daily tasks during these episodes. - **Bipolar II**: Involves less severe hypomanic episodes that are shorter in duration. People can usually maintain daily activities. - **Depressive Episodes:** - **Bipolar I**: People experience both mania and depression, but a depressive episode is not required for diagnosis. - **Bipolar II**: People experience depressive episodes and are often more affected by chronic depression compared to those with bipolar I. **Main Treatment Options** - **Medications** - **Mood Stabilizers**: These medications help control manic or hypomanic episodes. Examples include: - Lithium - Valproic Acid - Divalproex Sodium - Carbamazepine - Lamotrigine - **Antipsychotic**: These medications can help with manic or hypomanic episodes, or as maintenance treatment. Examples include: - Olanzapine - Risperidone - Quetiapine - Aripiprazole - Ziprasidone - Lurasidone - Cariprazine - Asenapine.  - **Antidepressants**: These medications can help with depression, but they can also trigger manic episodes. They are often used in combination with mood stabilizers or antipsychotics. - **Psychotherapy** - CBT  - **Education and support groups**: These can help patients, and their families learn about illness and how to cope.  **Comorbidity:** - 60% of people with Bipolar II have 3+ co-occuring mental disorders - 75% of people are anxious - Prevalent in children and youth, often present before the onset of bipolar symptoms - 37% have substance use disorders - 14% have experienced an eating disorder in their lifetime (Binge-eating Disorder is most common) **Cyclothymic Disorder** - **Diagnostic Criteria** a. **Duration of Symptoms**: For at least 2 years ( 1 year in youth), there have been numerous period with: i. Hypomanic Symptoms that do not meet full criteria for a full hypomanic episode ii. Depressive Symptoms that do not meet full criteria for a major depressive episode b. **Frequency of Symptoms:** iii. Over the 2 year period (1 year in youth) the symptoms have been present for at least half the time iv. The individual has not been symptom-free for more than 2 months at a time c. Criteria for a full manic, hypomanic, or depressive symptoms have been met Depressive Disorders Major Depressive Disorder - Diagnostic Criteria: - Symptoms: 5 or more of the following symptoms must be present during the same 2-week period and the must represent a change from previous functioning. At least one symptom must be depressed mood or loss of interest or pleasure - Depressed mood for most of the day, nearly every day (sadness, emptiness, hopeless, observed by others as tearful) - Diminished interest or pleasure in nearly all or all activities for most of the day - Significant weight change, increase or decrease of 5% of weight - Marked change in appetite everyday - Insomnia or Hypersomnia every day - Psychomotor agitation or retardation nearly everyday (observable by others) - Fatigue/Loss of Energy - Feelings of worthlessness or excessive/inappropriate guilt - Diminished ability to think or concentrate/indicisiveness - Recurrent thoughts of death, SI with/without plan, Suicide attempt - No hx of manic or hypomanic episodes - Treatment Options: - **Types of Antidepressants:** - **Selective serotonin reuptake inhibitors (SSRIs)** - First choice for treatment, generally safer with fewer side effects. - Examples: citalopram (Celexa), fluoxetine (Prozac), sertraline (Zoloft). - **Serotonin-norepinephrine reuptake inhibitors (SNRIs)** - Examples: duloxetine (Cymbalta), venlafaxine (Effexor XR). - **Atypical antidepressants** - Don't fit into other categories. - Examples: bupropion (Wellbutrin), mirtazapine (Remeron). - **Tricyclic antidepressants** - Effective but tend to have more severe side effects. - Examples: amitriptyline, nortriptyline (Pamelor). - **Monoamine oxidase inhibitors (MAOIs)** - Typically used when other drugs fail. - Examples: tranylcypromine (Parnate), phenelzine (Nardil). - **Other medications** - May be added to enhance effects, like mood stabilizers, antipsychotics, or anti-anxiety medications. - **Finding the Right Medication:** - You may need to try several medications or combinations, as antidepressants can take weeks to show effects. - Genetic tests can sometimes help predict how your body will respond to medication. - **Risks of Stopping Medication Abruptly:** - Don't stop without consulting your doctor as withdrawal symptoms or worsening depression can occur. - Gradual dose reduction is recommended. - **Antidepressants and Suicide Risk:** - Antidepressants may increase suicidal thoughts, especially in children, teenagers, and young adults under 25, in the first weeks of treatment or when doses change. - Close monitoring is essential during this time. - Psychotherapy - **Psychotherapy for Depression:** - Psychotherapy, or talk therapy, involves discussing your condition with a mental health professional. Effective types include: - **Cognitive Behavioral Therapy (CBT)** - **Interpersonal Therapy (IPT)** - **Benefits of Psychotherapy:** - Helps adjust to crises or difficulties. - Identifies and replaces negative beliefs and behaviors with healthier ones. - Explores relationships and experiences to improve interactions. - Develops coping skills and problem-solving abilities. - Identifies and changes behaviors that contribute to depression. - Regains a sense of control and satisfaction, easing symptoms like hopelessness and anger. - Teaches how to set realistic goals. - Help develop tolerance for distress with healthier behaviors. **Anxiety Disorders** - **Summary**: - **Overview of Anxiety Disorders:** Anxiety disorders are characterized by excessive fear and anxiety, often accompanied by behavioral disturbances. The key difference between fear and anxiety is their association with the present versus the future: - **Fear**: An emotional response to real or perceived imminent threats, typically involving **autonomic arousal** (fight or flight), thoughts of immediate danger, and **escape behaviors**. - **Anxiety**: A **future-oriented** response involving **muscle tension** and vigilance, preparing for possible threats, and often leading to **cautious or avoidant behaviors**. - **Panic Attacks:** A feature prominent across anxiety disorders, panic attacks can also occur in other mental health conditions. - **Panic attack**: A sudden surge of intense fear or discomfort, reaching a peak within minutes, often accompanied by physical and cognitive symptoms (e.g., rapid heart rate, difficulty breathing, fear of losing control). - Panic attacks can be **expected** (triggered by a known fear) or **unexpected** (occurring without a clear cause). - **Comorbidity**: - Anxiety disorders **often co-occur** with other anxiety disorders and other conditions such as depression, substance use disorders, and psychotic disorders. - They are more frequent in **females** than in males (approximately a 2:1 ratio). - **Types of Anxiety Disorders:** - **Separation Anxiety Disorder** - Excessive fear or anxiety regarding separation from attachment figures, leading to reluctance or refusal to go to school, work, or other situations away from the attachment figure. - **Physical symptoms** may include stomachaches, headaches, or nightmares about separation. - **Selective Mutism** - Consistent failure to speak in specific social situations (e.g., school), despite speaking in other settings. - This can significantly affect **academic** or **social functioning**. - **Specific Phobia**: - **Excessive fear or anxiety** about a specific object or situation (e.g., heights, animals, injections). - The anxiety is usually **immediate** and out of proportion to the actual threat posed by the feared object or situation. - **Social Anxiety Disorder (Social Phobia)**: - Fear or anxiety about being **scrutinized** in social or performance situations (e.g., public speaking, eating in front of others). - The person worries about **embarrassment**, **humiliation**, or rejection. - **Diagnostic Criteria:** A. **Fear or Anxiety About Social Situations:** The individual experiences intense fear or anxiety about situations where they may be **scrutinized** by others. a. **Social interactions**: Having a conversation, meeting new people. b. **Being observed**: Eating, drinking, or performing in front of others (e.g., giving a speech). c. **In children**, this fear or anxiety must occur specifically in **peer settings**, not just in interactions with adults. B. **Fear of Negative Evaluation:** The individual fears that they will act in a way or show anxiety symptoms that will lead to **negative evaluation** from others. This could involve: d. Being **humiliated** or **embarrassed**. e. Leading to **rejection** or **offending others**. C. **The Social Situations Almost Always Trigger Fear or Anxiety:** Social situations consistently **provoke** fear or anxiety. f. **In children**, this might be expressed by behaviors such as **crying**, **tantrums**, **freezing**, **clinging**, or **failing to speak** in social settings. D. **Avoidance or Endurance with Anxiety:** The individual either **avoids** the social situations entirely or **endures** them with intense fear or anxiety. g. The fear or anxiety is out of proportion to the **actual threat** posed by the situation and the **sociocultural context**. E. **Duration:** The fear, anxiety, or avoidance has persisted for **6 months or more**. F. **Functional Impairment:** The fear, anxiety, or avoidance **causes clinically significant distress** or **impairment** in **social**, **occupational**, or other important areas of functioning. G. **Not Attributable to Substance Use or Medical Condition:** The symptoms are **not caused** by the physiological effects of a **substance** (e.g., drugs, medication) or a **medical condition**. H. **Not Better Explained by Another Mental Disorder** - Specify if: **Performance Only:** - If the individual's fear is limited to speaking or performing in public (e.g., public speaking or performing on stage), they should be specified as having **Performance Only Social Anxiety Disorder**. - **Panic Disorder**: - Recurrent **unexpected panic attacks** and persistent worry about the occurrence of additional attacks or the consequences. - Individuals may change their behavior to avoid situations where panic attacks have occurred before. - **Diagnostic Criteria:** A. **Recurrent Unexpected** **Panic Attacks:** A **panic attack** is an abrupt surge of intense fear or discomfort that reaches its peak within **minutes** and is accompanied by **four (or more)** of the following symptoms: I. **Palpitations**, pounding heart, or accelerated heart rate. J. **Sweating**. K. **Trembling** or shaking. L. Sensations of **shortness of breath** or feeling smothered. M. Feelings of **choking**. N. **Chest pain** or discomfort. O. **Nausea** or abdominal distress. P. Feeling **dizzy**, unsteady, light-headed, or faint. Q. **Chills** or **heat sensations**. R. **Paresthesias** (numbness or tingling sensations). S. **Derealization** (feelings of unreality) or **depersonalization** (feeling detached from oneself). T. **Fear of losing control** or "going crazy." U. **Fear of dying**. ***Note**: The **abrupt surge** of panic can occur from a calm state or an anxious state.* B. **Post-Attack Symptoms:** V. At least **one** of the panic attacks is followed by **1 month (or more)** of either or both of the following: h. **Persistent concern or worry** about additional panic attacks or their consequences (e.g., fear of losing control, having a heart attack, \"going crazy\"). i. A **significant maladaptive change** in behavior due to the panic attacks, such as: i. Avoidance of exercise or unfamiliar situations. ii. Avoidance of situations that might trigger a panic attack. C. **Not Attributable to Substance Use or Medical Condition:** The panic attacks and related disturbance are **not attributable** to the physiological effects of a substance (e.g., drugs, medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). D. **Not Better Explained by Another Mental Disorder** E. **Duration**: The attack is typically **short-lived** (lasting around 10 minutes or less) but can feel like a prolonged experience. - **Agoraphobia**: - Fear or anxiety about being in situations where escape may be difficult, or help unavailable, in the event of experiencing panic-like symptoms. - Commonly avoided situations include **public transport**, **open spaces**, **crowds**, and **being outside alone**. - **Generalized Anxiety Disorder (GAD)**: - Chronic, excessive worry about a range of topics (e.g., work, health, school performance) that the individual cannot control. - Physical symptoms often include **restlessness**, **fatigue**, **difficulty concentrating**, **muscle tension**, and **sleep disturbances**. - **Diagnostic Criteria for Generalized Anxiety Disorder (GAD):** F. **Excessive Anxiety and Worry: Excessive anxiety and worry (apprehensive expectation)** occur more days than not for at least **6 months**, about several **events or activities**, such as work, school performance, health, or social interactions. G. **Difficulty Controlling the Worry** H. **Associated Symptoms:** The anxiety and worry are associated with **three (or more)** of the following **six symptoms** (with at least some symptoms being present for more days than not for the past 6 months): W. **Restlessness** or feeling keyed up or on edge. X. **Being easily fatigued**. Y. **Difficulty concentrating** or mind going blank. Z. **Irritability**. A. **Muscle tension**. B. **Sleep disturbance** (difficulty falling or staying asleep, or restless, unsatisfying sleep). ***Note**: Only **one item** is required for children to meet this criterion.* I. **Significant Distress or Impairment:** Anxiety, worry, or physical symptoms cause **clinically significant distress or impairment** in social, occupational, or other important areas of functioning. J. **Not Attributable to Substance or Medical Condition** K. **Not Better Explained by Another Mental Disorder** L. **Duration**: Symptoms must be present for **at least 6 months** to meet the diagnostic criteria, though they can persist longer without treatment. - **Anxiety Disorder Due to Another Medical Condition**: - Anxiety symptoms result from the physiological effects of an **underlying medical condition** (e.g., thyroid problems, heart disease). - **Diagnosis and Clinical Features:** - **Distinguishing Features**: While there is **overlap** in the symptoms of anxiety disorders, they can be differentiated based on: - The **specific objects** or **situations** that induce fear, anxiety, or avoidance. - The **content of associated thoughts** (e.g., fear of social rejection in social anxiety disorder vs. fear of a panic attack in agoraphobia). - **Substance/Medication-Induced Anxiety Disorder**: - Anxiety symptoms that are directly caused by substance **intoxication**, **withdrawal**, or **medication side effects**. - **Comorbidities**: - Anxiety disorders often **co-occur** with other mental health conditions. For instance: - Anxiety disorders are commonly co-occurring with **depression**. - **Substance use** disorders may develop in those with panic disorder or generalized anxiety disorder as individuals attempt to self-medicate. - **Management and Treatment:** - **Psychotherapy** - **Cognitive Behavioral Therapy (CBT)** is the most effective therapeutic approach for social anxiety, focusing on identifying and challenging negative thought patterns. - This is the first-line treatment for panic disorder, focusing on **cognitive restructuring** to challenge and change negative thinking patterns and **exposure therapy** to gradually confront feared situations - **Exposure therapy**: Gradual exposure to feared social situations can help reduce avoidance behaviors. - **Panic-focused psychodynamic therapy**: A therapeutic approach that aims to explore and address underlying emotional conflicts contributing to panic attacks. - **Mindfulness-Based Cognitive Therapy (MBCT)** is also helpful in managing anxiety by increasing awareness of the present moment and reducing excessive worry. - **Medications**: - Selective serotonin reuptake inhibitors (SSRIs) - Serotonin-norepinephrine reuptake inhibitors (SNRIs - **Benzodiazepines** may be prescribed for short-term relief of acute panic attacks but are generally not used long-term due to the risk of dependence. - **Buspirone** is another medication that can be used to treat GAD, particularly for long-term management as it has a lower risk of dependence compared to benzodiazepines. - **Lifestyle Changes:** - **Regular exercise** can help alleviate anxiety by releasing endorphins and promoting relaxation. - **Relaxation techniques**, such as deep breathing exercises, progressive muscle relaxation, and meditation, can help manage symptoms. - **Sleep hygiene** is important to address sleep disturbances and improve overall well-being. **Obsessive Compulsive and Related Disorders** - **Summary** - Obsessive-compulsive and related disorders (OCRDs) are a group of disorders characterized by: - **obsessions** and/or **compulsions** - other repetitive behaviors or mental acts - These disorders involve varying degrees of **preoccupation**, **distress**, and **impairment** in daily functioning. - They share common underlying mechanisms but also differ in specific symptoms and treatment approaches. - **Key Characteristics:** - **Obsessions**: These are **recurrent and persistent thoughts, urges**, or **images** that are experienced as intrusive and unwanted, causing **significant anxiety** or **distress**. - **Compulsions**: These are **repetitive behaviors** or **mental acts** that an individual feels driven to perform in response to an obsession or according to rigidly applied rules. The behaviors are aimed at reducing anxiety or preventing a feared event, even though the actions may be excessive or not connected to the feared event in a realistic way. - **Preoccupation with body-focused repetitive behaviors** (e.g., **hair-pulling**, **skin-picking**) is another feature of some OCRDs, which is distinct from obsessions and compulsions but shares similar patterns of distress and repeated attempts to stop the behavior. - **Key Disorders in the OCRD Category:** - **Obsessive-Compulsive Disorder (OCD):** - OCD involves persistent obsessions and/or compulsions. - Common themes include **cleaning**, **symmetry**, **forbidden thoughts**, and **harm** (e.g., fears of causing harm to oneself or others) - **Diagnostic Criteria:** - **Presence of Obsessions, Compulsions, or Both: Response**: To manage or neutralize the distress caused by these obsessions, the individual engages in behaviors such as: - **Ignoring** or **suppressing** intrusive thoughts. - Attempting to **neutralize** the thought by performing a **compulsion** (such as counting, checking, or washing). - **Compulsions** - These behaviors or mental acts are **performed to reduce anxiety** or distress, or to **prevent some feared event or situation**. - The behaviors often have no realistic connection to the event they are meant to prevent, or they are **excessive**. - ***Note for Young Children**: Young children may not be able to express in words why they are performing these behaviors, but compulsive actions still occur.* - **Time Consumption or Impairment** - **Exclusion of Substance/Medication or Medical Condition** - **Exclusion of Other Mental Disorders** - **Young Children**: Diagnosis in younger children may be more challenging due to their inability to articulate the reasons behind their compulsions or obsessions, but the behaviors still meet criteria for OCD. - **Chronic Nature**: OCD is typically a **chronic** condition, meaning it tends to persist over time if untreated. Early treatment, including **cognitive-behavioral therapy (CBT)** and **medication**, can improve prognosis. - **Body Dysmorphic Disorder (BDD):** - This disorder is characterized by a **preoccupation with perceived defects or flaws in physical appearance** that are either non-existent or minimal. - It leads to **repetitive behaviors** (e.g., mirror checking, excessive grooming) or **mental acts** (e.g., comparing oneself to others) in response to the concerns. - **Hoarding Disorder:** - Individuals with hoarding disorders experience persistent **difficulty discarding or parting with possessions** - leading to **accumulation** of items that clutter and compromise living spaces. - **Excessive acquisition** (collecting or buying items) is often a feature. - **Trichotillomania (Hair-Pulling Disorder):** - This disorder involves **recurrent pulling out of one's hair**, resulting in noticeable hair loss. There are **repeated attempts to stop hair-pulling** behavior. - **Excoriation (Skin-Picking) Disorder:** - Characterized by **recurrent skin picking** leading to **skin lesions**, and repeated attempts to reduce or stop the behavior. - **Substance/Medication-Induced OCRD:** - Symptoms that are directly related to **substance use** (e.g., intoxication or withdrawal) or **medications** that induce obsessive-compulsive behaviors. - **OCRD Due to Another Medical Condition:** - When symptoms are a **direct result** of a medical condition (e.g., brain injury or neurological disorder). - **Other Specified and Unspecified OCRDs:** - These categories include atypical presentations or when symptoms do not fit neatly into a specific disorder but share common features. Examples include **body-focused repetitive behavior disorder** or **obsessional jealousy**. - **Specifiers Based on Insight:** - **Good or Fair Insight**: The individual recognizes that their obsessions or compulsions are **excessive or unreasonable**. - **Poor Insight**: The individual believes their obsessions or compulsions are **probably true**. - **Absent Insight/Delusional Beliefs**: The individual has **delusional beliefs** about their obsessions and compulsions, leading to significant impairment. - **Note**: Individuals with **absent insight/delusional beliefs** should **not** be diagnosed with a psychotic disorder (e.g., **schizophrenia**), as the symptoms are related to the OCD spectrum and not a separate psychotic condition. - **Treatment Approaches:** - **Psychotherapy** - **Cognitive-Behavioral Therapy (CBT)**: Specifically, **Exposure and Response Prevention (ERP)** is the most effective form of therapy for OCD. It involves **exposing** individuals to fearful situations while preventing them from performing the compulsive rituals that they would normally use to reduce their anxiety. - **Other Approaches**: - **Habit Reversal Training (HRT)**: Used for behaviors like hair-pulling or skin-picking, focusing on increasing awareness of the behaviors and using alternative, healthier responses. - **Support Groups**: May be helpful for long-term management, providing social support and shared experiences. - **Medications**: - **Selective Serotonin Reuptake Inhibitors (SSRIs)**, such as **fluoxetine** (Prozac), **sertraline** (Zoloft), and **fluvoxamine**, are commonly prescribed for OCD. - **Antipsychotic medications** (e.g., **risperidone**) may be used in some cases, particularly for individuals with **poor insight**. - **Prognosis:** - **Chronic and Impairing**: Without treatment, OCRDs can be long-lasting and lead to significant distress, impairment in daily functioning, and difficulty maintaining relationships or employment. - **Treatment Response**: Many individuals experience symptom improvement with **CBT**, **medication**, or a combination of both. **\ Trauma and Stressor Related Disorders** - Summary - The Trauma- and Stressor-Related Disorders section in the DSM-5 covers a range of disorders that are directly tied to exposure to traumatic or stressful events. - These disorders differ significantly in terms of symptoms and how individuals respond to trauma. - While some individuals may experience anxiety or fear-related symptoms, others may display more anhedonic, dysphoric, angry, or dissociative behaviors. - These varied responses are grouped under trauma- and stressor-related disorders. - **Key Disorders in Trauma- and Stressor-Related Disorders** - **Reactive Attachment Disorder (RAD)** - **Definition**: RAD occurs in children who have experienced severe neglect or a lack of adequate caregiving early in life. This disorder is characterized by **withdrawn** and **emotionally distant** behaviors, particularly toward caregivers, and difficulty forming healthy attachments. - **Behavioral Symptoms:** - **Inhibited, emotionally withdrawn behavior** toward adult caregivers: - Rarely seek comfort when distressed. - Rarely respond to comfort when distressed. - **Social & Emotional Disturbance** (at least 2 of the following): - Minimal social and emotional responsiveness to others. - Limited positive effects. - Unexplained irritability, sadness, or fearfulness even in non-threatening situations. - **Causes:** - **Extreme insufficient care** (one of the following): - Social neglect or deprivation (lack of emotional comfort, stimulation, affection). - Frequent changes in primary caregivers (e.g., foster care). - Rearing in settings limiting attachment opportunities (e.g., institutions with high child-to-caregiver ratios). - **Specifiers:** - **Persistent**: Disorder present for **more than 12 months**. - **Severity**: Severe if **all symptoms** are present at high levels. - **Disinhibited Social Engagement Disorder (DSED)** - **Definition**: Like RAD, DSED occurs because of early childhood neglect or insufficient caregiving. - Children with DSED display **disinhibited** behaviors in which they overly engage with unfamiliar adults or strangers without hesitation. - **Symptoms**: - Overly familiar behavior with strangers (e.g., approaching unfamiliar adults without reservation) - Lack of boundaries or appropriate inhibition in interactions with unfamiliar adults - Limited social or emotional connection with primary caregivers - **Posttraumatic Stress Disorder (PTSD)** - **Definition**: PTSD occurs after an individual is exposed to a **traumatic event** that causes significant psychological distress. Symptoms of PTSD include **intrusive memories**, **hyperarousal**, **avoidance** of trauma-related stimuli, and **negative mood** changes. It's often a response to experiences like combat, sexual assault, accidents, or natural disasters. - **Diagnostic Criteria** - **Exposure to Traumatic Event(s):** Trauma exposure through at least one of the following: - Directly experiencing the trauma. - Witnessing the trauma as it occurred to others. - Learning that a close family member or friend experienced the trauma (violent or accidental). - Repeated or extreme exposure to details of traumatic events (e.g., first responders). - *Note*: Does not apply to exposure through media unless work-related. - **Intrusion Symptoms (one or more of the following, after trauma):** - Recurrent, involuntary, distressing memories of the event(s). - Recurrent distressing dreams related to the event(s). - Dissociative reactions (e.g., flashbacks). - Intense psychological distress at exposure to reminders of trauma. - Marked physiological reactions to reminders of trauma. - **Avoidance Symptoms (one or more of the following):** - Avoiding memories, thoughts, or feelings associated with the event. - Avoiding external reminders (e.g., people, places, activities) that trigger distress. - **Negative Cognitions and Mood (two or more of the following):** - Inability to remember important aspects of the trauma (due to dissociative amnesia). - Persistent negative beliefs about oneself or the world. - Distorted thoughts about the cause of the trauma, leading to self-blame. - A persistent negative emotional state (e.g., fear, guilt, shame). - Diminished interest in activities. - Feelings of detachment from others. - Inability to experience positive emotions. - **Alterations in Arousal and Reactivity (two or more of the following):** - Irritable behavior and angry outbursts. - Reckless or self-destructive behavior. - Hypervigilance. - Exaggerated startle response. - Problems with concentration. - Sleep disturbance (e.g., difficulty falling/staying asleep). - **Duration of Symptoms:** Must last more than 1 month for diagnosis. - **Clinically Significant Impairment**: Must cause distress or impairment in social, occupational, or other important areas of functioning. - **Exclusions**: Symptoms cannot be because of a substance or other medical condition. - Specify if: - With Dissociative Symptoms (Depersonalization and/or Derealization) - Depersonalization: Feeling detached from oneself or body. - Derealization: Experiencing surroundings as unreal or distorted. - With Delayed Expression: Symptoms may not fully manifest until 6 months after the trauma. - **Acute Stress Disorder (ASD)** - **Definition**: Like PTSD but occurs in the **first month** following exposure to a traumatic event. If symptoms persist beyond a month, it may evolve into PTSD. ASD is often marked by **dissociation** (e.g., feeling detached from the world or oneself) and **reexperiencing symptoms** like intrusive memories. - **Diagnostic Criteria** - **Exposure to Traumatic Event(s):** Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways: - Directly experiencing the traumatic event(s). - Witnessing the event(s) as they occurred to others. - Learning that the event(s) occurred to a close family member or friend (must be violent or accidental). - Repeated or extreme exposure to details of the traumatic event(s) (e.g., first responders or police officers). ***Note**: Does not apply to exposure via media unless work-related.* - **Nine or More Symptoms (from Five Categories)** - *Symptoms must begin or worsen after the traumatic event:* - **Intrusion Symptoms (at least 1):** - Recurrent, involuntary, intrusive distressing memories of the event. - Distressing dreams related to trauma. - Dissociative reactions (flashbacks) where the individual feels the trauma is recurring. - Intense psychological distress or physiological reactions in response to reminders or cues of the trauma. - **Negative Mood (at least 1):** - Persistent inability to experience positive emotions (e.g., happiness, satisfaction, loving feelings). - **Dissociative Symptoms (at least 1):** - Altered sense of reality (e.g., seeing oneself from another\'s perspective, feeling dazed, time slowing). - Inability to remember important aspects of the trauma (dissociative amnesia). - **Avoidance Symptoms (at least 1):** - Efforts to avoid distressing memories, thoughts, or feelings associated with the trauma. - Efforts to avoid external reminders (people, places, activities, etc.) of the trauma. - **Arousal Symptoms (at least 2):** - Sleep disturbance (difficulty falling/staying asleep, restless sleep). - Irritable behavior and angry outbursts (with little or no provocation). - Hypervigilance (excessive alertness). - Problems with concentration. - Exaggerated startle response. - **Duration** - Symptoms must persist for 3 days to 1 month after the trauma. - D. Clinically Significant Distress or Impairment - The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. - **Exclusions** - The disturbance is not attributable to substance use (e.g., medication, alcohol) or a medical condition (e.g., mild traumatic brain injury). - The disturbance is not better explained by a brief psychotic disorder. - **Adjustment Disorders** - **Definition**: These disorders involve **emotional or behavioral responses** to a specific stressor or change in life (e.g., moving to a new place, the death of a loved one, divorce, job loss). The symptoms are more **acute and proportional** to the stressor, but they cause **significant distress or impairment**. - **Symptoms**: - **Depressed mood**, **anxiety**, or **disturbance in conduct** - **Significant impairment** in functioning (social, occupational) - Symptoms occur **within three months** of the stressor and typically resolve once the individual adjusts or the stressor is mitigated - **Common Features Across These Disorders:** - **Exposure to Trauma or Stress**: In each disorder, exposure to a stressful or traumatic event plays a pivotal role in the development of symptoms. The type, severity, and context of the stressor (e.g., neglect vs. natural disaster) can influence the specific disorder. - **Diagnostic Criteria** - **Development of Symptoms** - Emotional or behavioral symptoms develop in response to an identifiable stressor(s). - Symptoms occur within 3 months of the onset of the stressor(s). - **Clinical Significance** - Symptoms cause: - Marked distress out of proportion to the stressor, considering cultural and external factors. - Significant impairment in social, occupational, or other areas of functioning. - **Exclusions** - Symptoms do not meet criteria for another mental disorder. - The disturbance is not an exacerbation of a preexisting condition. - Symptoms do not represent normal bereavement. - **Duration:** Symptoms **do not persist for more than 6 months** after the stressor, or its consequences have ended. - **Specify subtype:** - **With depressed mood**: Predominantly low mood, tearfulness, hopelessness. - **With anxiety**: Predominantly nervousness, worry, jitteriness, or separation anxiety. - **With mixed anxiety and depressed mood:** Combination of depression and anxiety. - **With disturbance of conduct:** Predominantly conduct disturbance. - **With mixed disturbance of emotions and conduct:** Both emotional symptoms (depression, anxiety) and conduct disturbance. - **Unspecified:** Maladaptive reactions that don\'t fit specific subtypes. - **Varied Clinical Presentations**: - **Anxiety and fear-based symptoms** are common in PTSD and ASD, whereas **internalizing behaviors** (e.g., withdrawal, depression) are more typical in **Reactive Attachment Disorder (RAD)**. - Disorders like **Adjustment Disorder** may have **mixed or ambiguous** symptomatology (e.g., depression, anxiety, irritability, conduct changes). - **Dissociative symptoms** (e.g., emotional numbing, detachment) are significant in **ASD** and **PTSD** but can also appear in other disorders. - **Externalizing behaviors**, such as anger or aggression, may be noted in children with DSED. - **Relationships with Other Disorders:** - These disorders can often overlap or present with **comorbid conditions**. For example: - A person with **PTSD** may also experience **depression**, **anxiety**, or **substance use disorders**. - Individuals with **Adjustment Disorder** might later develop **anxiety disorders** or **depression** if they fail to adjust to a major life change. - Some of the symptoms of trauma-related disorders can overlap with **anxiety disorders**, **mood disorders**, and **dissociative disorders**, making careful diagnosis crucial. - **Treatment Approaches:** - **Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)**: This evidence-based treatment is especially effective for children and adolescents with **PTSD**, **acute stress disorder**, or **adjustment disorders**. It focuses on helping the individual process the traumatic experience, reduce distressing thoughts, and build coping skills. - **EMDR (Eye Movement Desensitization and Reprocessing)**: A specialized form of psychotherapy often used for treating **PTSD**. It helps individuals process traumatic memories and reduce distress related to trauma. - **Family Therapy and Support**: For children with **RAD** or **DSED**, family therapy is often necessary to address attachment issues, improve caregiver-child interactions, and support family dynamics. - **Medications**: - **Selective serotonin reuptake inhibitors (SSRIs)** such as **sertraline** and **paroxetine** are commonly prescribed for PTSD and other trauma-related disorders. - **Prazosin** may be used for **nightmares** related to PTSD. - **Trauma-Informed Care**: For those with **Reactive Attachment Disorder (RAD)** and **Disinhibited Social Engagement Disorder (DSED)**, therapeutic interventions focus on **safe, stable, and nurturing relationships**. Children with RAD may require **attachment-focused therapy** to help them build healthier emotional bonds, while children with DSED may benefit from programs that teach them appropriate social boundaries. **\ ** **Dissociative Disorders** - **Summary** - Dissociative disorders involve disruptions in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. - **Positive symptoms**: Unbidden intrusions (e.g., fragmentation of identity, depersonalization, derealization). - **Negative symptoms**: Inability to access or control mental functions (e.g., amnesia). - **Link to Trauma**: Dissociative disorders are often seen after trauma. Symptoms may be influenced by trauma proximity, including confusion, embarrassment, and a desire to hide symptoms. - **Specific Disorders:** - **Depersonalization/Derealization Disorder:** - **Symptoms**: Persistent or recurrent depersonalization (feeling detached from one\'s mind, body, or self) and/or derealization (feeling detached from surroundings). - **Reality testing intact**: Individuals can recognize that their experience is not real. - **Diagnostic Criteria**: - **Persistent or Recurrent Experiences**: - **Depersonalization**: Feelings of unreality or detachment from one\'s thoughts, feelings, body, or actions (e.g., feeling like an outside observer, emotional or physical numbing, distorted sense of time) - **Derealization**: Feelings of unreality or detachment from one\'s surroundings (e.g., people or objects seem unreal, dreamlike, or distorted). - **Reality Testing Remains Intact**: During episodes of depersonalization or derealization, the person is aware that their experiences are not real, maintaining **intact reality testing**. - **Distress and Impairment**: Symptoms cause **clinically significant distress** or **impairment** in social, occupational, or other important areas of functioning. - **Exclusion of Substance and Medical Causes**: Symptoms are **not because of a substance** (e.g., drug use, medication) or **medical conditions** (e.g., seizures). - **Dissociative Amnesia** - **Symptoms**: Inability to recall autobiographical information, typically localized (specific event) or selective (part of an event). - **Fugue state**: May involve bewildered wandering or travel (more common in dissociative identity disorder). - **Amnesia for Amnesia**: Many individuals are unaware of their memory gaps until prompted by external factors (e.g., discovering lost time or being told about events they cannot recall). - **Dissociative Identity Disorder (DID)** - **Diagnostic Criteria**: - **Disruption of Identity**: - Characterized by **two or more distinct personality states** or experiences of possession in some cultures. - Marked discontinuity in: - - **Sense of self** - **Sense of agency** - Associated with **alterations** in: - Affect - Behavior - Consciousness - Memory - Perception - Cognition - Sensory-motor functioning - These changes may be **observable by others** or reported by the individual - **Memory Gaps**: - Recurrent **gaps in memory** for: - Everyday events - Important personal information - Traumatic events - These memory gaps are **inconsistent with ordinary forgetting**. - **Distress and Impairment** in ADLS - **Exclusion of Other Causes** - Symptoms are **not attributable to**: - **Substance effects** (e.g., blackouts, chaotic behavior from alcohol intoxication). - **Medical conditions** (e.g., complex partial seizures). - **Other Specified Dissociative Disorder (OSDD)** - **Examples**: - Chronic or recurrent mixed dissociative symptoms (falling short of DID criteria). - Dissociative states due to brainwashing or thought reform. - Acute presentations of mixed dissociative symptoms with psychotic symptoms (lasting \< 1 month). - Single-symptom dissociative states (e.g., dissociative trance, stupor, Ganser\'s syndrome). - - **Summary** - **Definition**: Characterized by **persistent disturbances** in eating or eating-related behaviors, leading to altered food consumption and absorption. - These disturbances significantly **impair physical health** or **psychosocial functioning**. - **Diagnoses Included**: - **Pica** - Persistent consumption of nonfood items for at least one month. - This behavior must be developmentally inappropriate, not culturally accepted, and significant enough to require clinical attention if it occurs alongside other conditions. - **Rumination Disorder:** - Repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. - Not due to medical condition (e.g., gastrointestinal issues). - Occurs for at least one month. - Often associated with distress or impairment in social, academic, or occupational functioning. - **Avoidant/Restrictive Food Intake Disorder (ARFID)**: - Persistent failure to meet nutritional needs, leading to significant weight loss, nutritional deficiency, or dependence on supplements. - Not motivated by concerns about body weight or shape (unlike anorexia nervosa). - May involve a limited variety of foods or fear of eating. - Can lead to significant interference with daily functioning. - **Anorexia Nervosa**: - **Restriction of energy intake** leading to significantly low body weight (in the context of age, sex, development, and physical health). - **Intense fear of gaining weight** or becoming fat, or persistent behavior that interferes with weight gain. - **Disturbance in the way one\'s body weight or shape is experienced**, undue influence of body weight or shape on self-evaluation, or lack of recognition of the seriousness of low body weight. - Subtypes: - **Restricting type**: Weight loss achieved through dieting, fasting, or excessive exercise. - **Binge-eating/purging type**: Involves binge eating or purging (e.g., vomiting, misuse of laxatives). - **Bulimia Nervosa**: - **Recurrent episodes of binge eating**, characterized by: - Eating an excessive amount of food in a discrete period. - A sense of lack of control over eating during the episode. - **Recurrent inappropriate compensatory behaviors** to prevent weight gain (e.g., vomiting, misuse of laxatives, fasting, excessive exercise). - **Binge eating and compensatory behaviors occur at least once a week for 3 months.** - **Self-evaluation is unduly influenced by body shape and weight.** - The disturbance does not occur exclusively during episodes of anorexia nervosa. - **Binge-Eating Disorder**: - **Recurrent episodes of binge eating**, characterized by: - Eating an excessive amount of food in a discrete period. - A sense of lack of control over eating during the episode. - **Marked distress** regarding binge eating. - **Binge eating occurs at least once a week for 3 months.** - The episodes are not associated with inappropriate compensatory behaviors (such as purging, fasting, or excessive exercise) and do not occur during anorexia nervosa or bulimia nervosa. - May lead to significant distress or impairment in functioning (e.g., social, occupational). - **Obesity**: - **Obesity** is not considered a **mental disorder** in DSM-5. - Obesity results from **excess energy intake** relative to expenditure and is influenced by **genetic, physiological, behavioral, and environmental factors**. - Although obesity is not a mental disorder, there are strong associations with **mental health conditions** (e.g., binge-eating disorder, depression, schizophrenia) and may result from the side effects of certain **psychotropic medications**. - Obesity may also be a **risk factor** for the development of **mental disorders**, particularly **depression**. **\ Substance Use Disorder** - **Substance Classes**: - **10 Separate Drug Classes**: Alcohol, caffeine, cannabis, hallucinogens (including phencyclidine), inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other/unknown substances. - **Common Mechanism**: - **Reward System Activation**: All substances of abuse activate the brain\'s **reward system**, producing intense pleasure (\"high\"). This activation can overshadow normal, healthy activities. - **Vulnerability to Substance Use Disorders**: - Individuals with lower self-control or impaired brain inhibitory mechanisms may be more prone to developing substance use disorders, often exhibiting problematic behaviors before substance use begins. - **Gambling Disorder**: - Gambling is included in this section due to its **similar activation of the reward system**, resembling behaviors seen in substance use disorders. - **Other Behavioral Addictions**: - Behaviors like **Internet gaming**, **sex addiction**, **exercise addiction**, or **shopping addiction** have been discussed, but there is insufficient evidence to include them as formal mental disorders in DSM-5. - **Two Major Categories of Substance-Related Disorders**: - **Substance Use Disorders**: Problems with the use of substances. - **Substance-Induced Disorders**: Includes **intoxication**, **withdrawal**, and mental disorders caused by substances (e.g., psychotic disorders, depression, anxiety). - **Substance Intoxication:** - **Intoxication** is the development of a **reversible substance-specific syndrome** caused by recent ingestion of a substance. - **Criteria for Intoxication**: - A substance-specific syndrome develops due to recent ingestion. - Clinically significant behavioral or psychological changes (e.g., mood changes, impaired judgment, belligerence) occur due to the substance\'s physiological effects on the CNS, appearing during or shortly after use. - The symptoms are not due to another medical condition or better explained by another mental disorder. - **Common Symptoms**: - Disturbances in **perception**, **attention**, **thinking**, **judgment**, **psychomotor behavior**, and **interpersonal behavior** - Intoxication can be **acute** (short-term) or **chronic** (sustained) with varying signs and symptoms depending on the substance and duration of use. - **Tobacco Exclusion**: **Tobacco** use is not included under this category of intoxication. - **Substance Withdrawal:** - **Withdrawal** occurs when there is a **cessation or reduction** in heavy, prolonged substance use, leading to a substance-specific syndrome. - **Criteria for Withdrawal**: - Problematic behavioral and physiological changes develop due to cessation or reduction of substance use. - Withdrawal causes clinically significant distress or impairment in important areas of functioning (e.g., social, occupational). - Symptoms are not caused by another medical condition or better explained by another mental disorder. - **Common Symptoms**: typically include **physiological and cognitive changes** (e.g., anxiety, tremors, nausea), and individuals often have a strong urge to re-administer the substance to relieve these symptoms. - **Association with Substance Use Disorder**: Withdrawal is **commonly** associated with substance use disorders but can occur in individuals without such a disorder. - **Alcohol Use Disorder** - **Diagnostic Criteria** - Problematic Pattern of Alcohol Use: - To be diagnosed with alcohol use disorder, the individual must meet at least two of the following criteria, occurring within a 12-month period: - **Larger Amounts or Longer Duration:** - Alcohol is often consumed in larger amounts or over a longer period than was initially intended. - **Persistent Desire or Unsuccessful Efforts to Cut Down:** - There is a persistent desire or unsuccessful efforts to reduce or control alcohol use. - **Significant Time Spent on Alcohol-Related Activities:** - A great deal of time is spent obtaining, using, or recovering from alcohol\'s effects. - **Craving**: There is a strong desire or urge to use alcohol. - **Failure to Fulfill Major Role Obligations in School, Work or at Home** - **Social or Interpersonal Problems:** Alcohol use continues despite persistent, or recurrent social or interpersonal problems caused or worsened by alcohol. - **Reduction in Social, Occupational, or Recreational Activities:** Important activities, like social, occupational, or recreational activities, are reduced or abandoned due to alcohol use. - **Recurrent Use in Hazardous Situations:** Recurrent alcohol use occurs in situations where it is physically hazardous. - **Continued Use Despite Physical or Psychological Problems:** Alcohol use continues despite knowledge of having a physical or psychological problem likely caused or exacerbated by alcohol. - **Tolerance (one of the following):** - **Increased Amounts**: A markedly increased need for alcohol to achieve intoxication or the desired effect. - **Diminished Effect:** A markedly diminished effect with continued use of the same amount of alcohol. - **Withdrawal (one of the following):** - **Characteristic Withdrawal Syndrome**: Exhibiting the withdrawal syndrome for alcohol (refer to alcohol withdrawal criteria). - **Relief of Withdrawal:** Alcohol (or a similar substance like benzodiazepines) is used to relieve or avoid withdrawal symptoms. - *Specify if:* - **In Early Remission:** - After meeting full criteria for alcohol use disorder, none of the criteria for alcohol use disorder have been met for at least 3 months but less than 12 months. - Craving (A4) may still be present. - **In Sustained Remission:** - After meeting full criteria for alcohol use disorder, none of the criteria for alcohol use disorder have been met for 12 months or longer. - Craving (A4) may still be present. - **In a Controlled Environment:** - This specifier is used if the individual is in an environment where access to alcohol is restricted. - **Alcohol Intoxication:** - Recent consumption of alcohol leads to clinically significant behavioral or psychological changes (e.g., mood lability, impaired judgment, aggression). - **Symptoms may include:** - Slurred speech - Incoordination - Unsteady gait - Nystagmus (involuntary eye movement) - Impaired attention or memory - Stupor or coma - Severity of intoxication can vary, but it must cause clinically significant distress or impairment in functioning. - **Alcohol Withdrawal:** - Cessation or reduction in alcohol use following prolonged, heavy use. - **Symptoms typically develop within hours to a few days of stopping or reducing alcohol consumption and can include:** - Autonomic hyperactivity (e.g., sweating, increased heart rate) - Hand tremor - Insomnia - Nausea or vomiting - Hallucinations (visual, tactile, or auditory) - Seizures (can be life-threatening) - Anxiety or irritability - Severity ranges from mild to severe (e.g., delirium tremens), depending on symptoms and medical complications. - **Stages of Alcohol Withdrawal** - **Stage One (6 to 12 hours):** - Symptoms: Headaches, anxiety, stomach pains, insomnia, poor appetite, nausea. - **Stage Two (12 to 48 hours):** - Symptoms escalate: Hallucinations, seizures. - **Stage Three (48 to 72 hours):** - Severe symptoms: Fever, sweating, confusion, rapid heart rate, high blood pressure, and **delirium tremens (DTs)**, a potentially fatal condition. - **Stage Four (72 hours to 7 days):** - Symptoms start to improve gradually over the next 4 to 7 days. - ***Delirium Tremens (DTs):*** - A severe alcohol withdrawal symptom, marked by **delirium** and altered **consciousness**. - Can be fatal in **5% to 15%** of cases. - Higher risk in: - Older individuals - Those with a history of heavy alcohol use - Previous DTs - Poor liver function - More severe withdrawal symptoms at the outset. - **Treatment for Alcohol Withdrawal:** - **Medical Supervision**: Best handled by professionals in a detox program or rehab facility. - Important for those with severe withdrawal symptoms, as detoxing alone can be dangerous. - **Typical Treatments for Alcohol Withdrawal:** - **Initial Observations**: To assess the severity of withdrawal symptoms. - **Medications:** - **Anti-anxiety Medications**: Benzodiazepines to reduce anxiety caused by withdrawal. - Chlordiazepoxide (e.g., Librium). - Clorazepate (e.g., Tranxene). - Diazepam (e.g., Valium). - Oxazepam (e.g., Serax). - **Anti-seizure Medications/Anti-Convulsants**: - Carbamazepine (e.g., Tegretol) - Gabapentin (e.g., Neurontin) - Oxcarbazepine (e.g., Trileptal) - Valproic Acid (e.g., Depakene) - **Beta-blockers**: Used to slow heart rate, reduce tremors, improve anxiety, and sometimes help with alcohol cravings. - **Barbiturates** - **Alcohol Intake Prevention Medications** - **Naltrexone** - **Importance of Skilled Rehab Centers:** - Detox is mentally, physically, and emotionally challenging. - Competent professionals in rehabilitation centers can safely supervise detox and manage symptoms. - **Tapering off alcohol alone** is rarely effective for treating alcohol addiction and can be unsafe. ***Note**: Withdrawal and detox are tough but crucial first steps toward recovery.* - **Factors That May Influence the Detox Timeline** - Amount of alcohol typically consumed - How often the person has been drinking on a regular basis - Weight - Age - Whether alcohol is combined with other substances - Whether co-occurring mental health conditions like depression, anxiety or eating disorders are present - Additional physical health problems - **Other Alcohol-Induced Disorders:** - This category includes a range of conditions caused by alcohol consumption, such as: - **Alcohol-Induced Psychotic Disorder:** Delusions or hallucinations caused by alcohol use. - **Alcohol-Induced Mood Disorder:** Depression or mania resulting from alcohol use. - **Alcohol-Induced Anxiety Disorder:** Anxiety symptoms induced by alcohol use. - **Alcohol-Induced Sexual Dysfunction**: Sexual difficulties related to alcohol consumption. - Symptoms are directly related to alcohol use and improve with cessation of alcohol consumption. - **Unspecified Alcohol-Related Disorder (DSM-5 Diagnostic Criteria):** - This diagnosis is used when alcohol-related symptoms or problems are present, but the specific disorder (e.g., intoxication, withdrawal, alcohol use disorder) cannot be clearly determined. - It is used when the exact nature of the alcohol-related issue is unclear, or when insufficient information is available to make a specific diagnosis. **Neurocognitive Disorders** **Delirium** - **Diagnostic Criteria** - **Disturbance in Attention and Awareness**: - **Attention**: Reduced ability to **direct**, **focus**, **sustain**, and **shift** attention - **Awareness**: Reduced **orientation to the environment**. - **Acute Onset and Fluctuating Course**: - The disturbance **develops over a short period** of time, typically **hours to a few days** - It represents a **change from baseline** in attention and awareness. - The severity of symptoms **fluctuates throughout the day**. - **Additional Cognitive Disturbance**: - There is an additional disturbance in **cognition**, such as: - - **Memory deficit**. - **Disorientation**. - **Language** issues. - **Visuospatial ability** impairments. - **Perception** disturbances (e.g., hallucinations). - - **Exclusion of Other Neuro