deck_3996887 Flashcards
(163 cards)
1
Q
What are the essential features of the intellectual disability (intellectual developmental disorder)?
A
- general mental abilities(deficits in their ability to think)2. impairment in everyday adaptive functioning (ability to adapt to the normal demands of normal life)
2
Q
What are the three areas of adaptive functioning?
A
Intellectual Developmental Disorder1. Conceptual(academic): depends on language, math, reading, writing, reasoning, and memory to solve problems, judgment in novel situations2. Social: awareness of other’s thoughts, feelings, and experiences; empathy, interpersonal communication, social judgement, and friendship abilities, self-regulation3. Practical: regulating behavior, organizing tasks, money management, personal care, job responsibilities, and recreation.The patient’s success on adaptations depends on patient’s education, job training, motivation, personality, support from significant others, and intelligence level.
3
Q
What qualifies an Intellectual Developmental Disorder (IDD) and what are the different levels of severity?
A
Mild(50-70)85%of all patients with IDD, Moderate(high 30s to low 50s) represent 10% of all patients with IDD, Severe (low 20s to high 30s) roughly make up 5% of all IDD patients, Profound (low 20s downward)IQ needs to be two standard deviations from the norm, Plus at least one domain of adaptive functioning
4
Q
What is the Borderline Intellectual Functioning IQ range?
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71-84, persons who do not have the coping problems associated with intellectual disability
5
Q
What is the age of onset of Intellectual Developmental Disability?What are behavioral problems commonly associated with Intellectual Developmental Disability?
A
Age of onset typically during childhood and adolescence-even before birth.If behavior begins at age 18 or after, it is called a MAJOR NEUROCOGNITIVE DISORDER (Dementia)-Dementia &Intellectual Developmental Disability can coexist.Behavioral problems: aggression, dependency, impulsivity, passivity, self-injury, stubbornness, low self-esteem, and poor frustration tolerance. Gullibility and naivete can lead to risk for exploitation by others.
6
Q
Describe some of the etiologies of Intellectual Developmental Disabilities.
A
- Genetic causes (about5%) Chromosomal abnormalities, Tay-Sachs, tuberous sclerosis2. Early pregnancy factors (about 30%). Trisomy 21(Down syndrome), maternal substance use, infections3. Later pregnancy and perinatal factors(about 10%) Prematurity, anoxia, birth trauma, fetal malnutrition4. Acquired childhood physical conditions (about5%) Lead poisoning, infections, trauma5. Environmental influences and mental disorders(about 20%) Cultural deprivation, early-onset schizophrenia6. No identifiable cause (about 30%)
7
Q
Describe Differential Diagnosis for Intellectual Developmental Disorder.
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- Cognitive Disorders (e.g., Down’s syndrome that gets a head injury and declines cognitive functioning, or develops Alzheimer’s disease- can have both diagnosis IDD and neurocognitive disorder dx)2. Communication Disorders and Specific Learning Disorders3. Autism Spectrum Disorder
8
Q
By Law the term Developmental Disability is used and applied to anyone who by age of…
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22 has permanent problems functioning in at least three areas because of mental or physical impairment.
9
Q
Global Developmental Delay is Diagnosed for patients under the age of…
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age 5, who have not been adequately evaluated.Such child may have delayed developmental milestones
10
Q
Autism Spectrum Disorder requires deficits in both areas by level of severity(level 1mild, level2moderate, and level3severe)
A
Assess these two areas separately:1. Communication and Socialization: COMMUNICATION:speak clearly or others have unusual speech patterns and idiosyncratic use of phrases. May speak too loudly or lack prosody(lilt) that supports the music of normal speech.Fail to use body language or other nonverbal behavior to communicate. may not understand basis of humor, may have problems understanding abstract meaning, trouble beginning or sustaining conversation, may talk to selves or hold monologues on subjects that interest them but not to other people. May ask questions over and over even after obtained repeated answer.SOCIALIZATION: slower maturation than normal children; parents in the second 6 months concerned when child not make eye contact, smile reciprocally, or cuddle, instead arch away from parent’s embrace and stare in space. Toddlers don’t point to objects or play with other children. They may not stretch their arms to be picked up or show normal anxiety at separation from parents. As a result of frustration of inability to communicate, results in tantrums and aggression in young children. little requirement for closeness, older children have few friends and seem not to share toys or sorrows with other people. In adolescence and beyond, absent need for sex. 2. Motor Behavior(Restricted, repetitive patterns of behavior, interests, or activities-RRBs): Motor milestones usually arrive on time. Compulsive or ritualistic actions (called stereotypies)-twirling, rocking, hand flapping, head banging, and maintaining odd body postures that mark them as different. Suck on toys or spin them rather then use them as symbols for imaginative play. Their restrictive insterests lead them to adhere to rigidly to routine. Appear indifferent to pain or extremes of temperature; preoccupied with smelling or touching things. Injure selves by head banging, skin picking, or repetitive motions.
11
Q
How many patients with Autism Spectrum Disorder have sensory abnormalities?
A
90%; some children hate bright lights, loud sounds, even prickly texture of certain fabrics or other surfaces. A small minority have “splinter” skills–special abilities in computation, music, or rote memory that occasionally rise to the level of savantism.
12
Q
What are physical conditions associated with Autism Spectrum Disorder?
A
phenylketonuria, fragile X syndrome, tuberous sclerosis, and a history of perinatal distress.
13
Q
Comorbidity with other mental disorders and Autism Spectrum Disorder?
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Anxiety(especially prevalent), depression(2-30%), OCD (1/3), ADHD(1/2), Intellectual disability(1/2), and seizures(25-50%)Some patients complain of initial insomnia or reduced need for sleep; a few even sleep days and remain awake nights. Researchers have recently reported association of a form of autism with a gene responsible for kidney, breast, colon, brain, and skin cancer.
14
Q
What is Autism Spectrum Disorder prevalence?
A
Incorporating the former diagnoses of autistic, Rett’s, Asperger’s and childhood disintegrative disorders, Austistic Disorder’s overall prevalence is about 6 per 1,000 children in the general population. Affects all cultural and socioeconomic groups. BOYS twice or up to four times as often affected as girls. Siblings of patients with Autism Spectrum Disorder have a greater elevated risk for the same disorder.
15
Q
Describe different levels for Autism Spectrum Disorder
A
Social CommunicationLevel1 (Mild): The patient has trouble starting conversations or may seem less interested than most people in social interactions.Code as “Requiring Support”Level2(Moderate): There are marked deficits in both verbal and nonverbal communication. Code as “Requiring substantial support.”Level3(Severe): Little response to the approach of others markedly limits functioning.Speech is limited, perhaps to just a few words. Code as “Requiring very substantial support.”Restricted, repetitive behaviorsLevel1(Mild): Inflexibility of behavior causes significant interference with functioning in one or more contexts. Change provokes some problems in at least one area of activity. Code as “Requiring Support.”Level2(Moderate): Problems in coping with change are readily apparent and interfere with functioning in various areas of activity. Code as “Requiring substantial support.”Level3(Severe): Change is exceptionally hard; all areas of activity are influenced by behavioral rigidity. Causes severe distress. Code as “Requiring very substantial support.”
16
Q
What are the Differential Diagnoses for Autism Spectrum Disorder?
A
normal children may have strong preferences and enjoy repetition; consider intellectual developmental disorder, stereotypic movement disorder, obsessive-compuslive disorder(OCD), social anxiety disorder, language disorders and social(pragmatic) communication disorder, -Rett’s syndrome, ADHD, Selective Mutism, Schizophrenia
17
Q
Describe Attention-Deficit/Hyperactivity Disorder criteria
A
- Inattention: difficulty paying attention, maintaining focus on their work or play, distracted, neglect details, and make careless mistakes, poor organization skills, lost assignments, inability to follow through with chores or appointments2. Hyperactivity/Impulsivity: forever in motion, fidgets, disruptive in class, restless, jumps out of seat, talking endless, interrupting others, seeming unable to take turns or to play quietly, runs, or climbs.Duration 6+ months; Onset before age 12(raised from 7 years) For Adults or adolescents age 17 years need 5 symptoms from criteria A1. Inattention. Disability-work/educational, social or personal impairment in at least 2 or more settings
18
Q
What are differential Diagnoses for Attention-Deficit/Hyperactivity Disorder?
A
intellectual disability, anxiety, and mood disorders, autism spectrum disorder, conduct disorder, oppositional defiant disorder, intermittent explosive disorder, specific learning disorders, disruptive mood dysregulation disorder, psychotic disorders, or other mental or personality disorders
19
Q
Prevalence for Attention-Deficit/Hyperactivity Disorder
A
Males 2:1 than females in general population, with a ratio of 2:1 in children and 1.6:1 in adults; Females more likely to present primarily with inattentive features;Runs in families-Parents and siblings more likely than average to be affected. Alcoholism and divorce as well as other causes of family disruption common in family backgrounds with ADHD.
20
Q
Other Disorders associated with Attention-Deficit/Hyperactivity Disorder?
A
Also, genetic association with antisocial personality disorder and somatic symptom disorder. Also ADHD are learning disorders, problems reading. In adults, look for substance use, mood, and anxiety disorders.Other disorders-co-occur with ADHD-Oppositional defiant disorder and conduct disorder, each in a substantial minority of patients with ADHD. Disruptive mood dysregulation disorder may be even more strongly associated. Specific learning disorders, OCD, tic disorders. Adults may have antisocial personality disorder and substance use problem.
21
Q
When would Other or Unspecified Attention-Deficit/Hyperactivity Disorder be used?
A
with patients with prominent symptoms that do not fulfill the criteria for ADHD proper. Examples would include people whose symptoms begin after the age 12 or whose symptoms are too few. Impairment is key to qualify. If want to specify the reason why ADHD doesn’t work for the patient, choose F90.8[314.01]Other ADHD and tack on something like “symptoms first identified at age 13.” otherwise choose unspecified.
22
Q
Essential features for Tic Disorders (compared)
A
Touretts’s Persistent(chronic)motor/ Provisionaldisorder or vocal tic disorder tic disordertype1+vocal tic& motor or vocal motor or vocal tics2+motor tics tics, but NOT both or both, in any (beginby18,typically age 4-6) quantityDurationLonger than 1 year longer 1year less than 1yrALL must begin by age 18—————————– Motor tics only or————————— specify if vocal tics onlyTic definitionALL Abrupt, nonrhythmic, quick , repeated
23
Q
Differential Diagnoses for Tourette’s Disorder
A
OCD, other Tic Disorders, substance use, and physical disorders-In Tourette’s Disorder, motor and vocal tics need not occur in the same time frameThe best tic of all–caprolalia-swear words and other socially unacceptable speech-is relatively uncommon.
24
Q
Essential Features of Language Disorder and Describe Differential Diagnoses
A
Beginning in childhood, a patient’s use of spoken and written language consistently lags behind age expectations. Compared to age-mates, patients will have small vocabularies, impaired use of words to form sentences and reduced ability to employ sentences to express ideas.Differential Diagnoses: sensory impairment, autism spectrum disorder, intellectual disability, learning disorder-though these can coexist with Language Disorder
25
Essential Features of Speech Sound Disorder(aka phonological disorder)AND Describe Differential Diagnoses
Problems producing the sounds of speech, compromising communication. EX: lisping, "gaspetti" for spaghetti, not errors found in those who learn English as a second language.Condition is familial and can occur with other language disorders, anxiety disorders, including selective mustism, and ADHD.Differential Dx: physical disorders such as cleft palate or neurological disorders; sensory impairment such as hearing impairment; selective mutism
26
Essential Features of Childhood-Onset Fluency Disorder(aka stuttering) and Differential Dx
Stutterring is reported by people to cause anxiety or frustration, even physical tension. Children are observed clenching their fists or blinking their eyes in effort to regain control when there is extra pressure to succeed (as when speaking to a group). Stuttering occurs especially with consonants; the initial sounds of words, the first word of a sentence, and words that are accented, long, or seldom used. It may be provoked by a joke telling, saying one's name, talking to strangers, or speaking to authority figures. Stutterers often find that they are fluent when singing, swearing, or speaking to the rhythm of a metronome.-On average stuttering starts at age 5 but can begin as young as 2. Sudden onset may correlate with greater severity. As many as 3% of young children stutter; % higher for children with brain injuries or intellectual disability. Boys outnumber girls at least 3:1. Adults 1:1000, of whom 80% male. Runs in families. Genetic component and links to Tourette's disorder, which is a dopamine related disorder; dopamine antagonists have been used to ameliorate the effects of stuttering.Differential Dx: Speech motor deficits; neurological conditions such as stroke; other mental disorders
27
Essential Features of Social(Pragmatic) Communication Disorder and describe Differential Dx
Despite adequate vocabulary and ability to form sentences, persons still have problems with the practical use of verbal and nonverbal language.This is called pragmatics:using language for social reasons, adapting communication to fit the context, following the conversations (rules) of conversation, and understanding implied communications.usually identified by age 4-5\*If patient has difficulty understanding and using pragmatic aspects of social communication to the point that their conversations can be socially inappropriate. Yet, they do not have the restricted interests and repetitive behaviors that would qualify them for a diagnosis of autism spectrum disorder.Differential dx: physical or neurological conditions, autism spectrum disorder, intellectual disability, learning disorders, social anxiety disorder, ADHD
28
Essential Features of Specific Learning Disorder
Impairment in:1. Reading(Dyslexia): several forms...difficulty with comprehension or speed when the person is reading silently; with accuracy when the person is reading aloud; when person trying to spell. Normally distributed throughout population and occurring at every intelligence level, dyslexia affects about 4% of school-age children, most of them boys.Dyslexia attributed to environmental factors(lead poisoning, fetal alcohol syndrome, low ses) and familial causes (inheritance may account for 30% of cases).Clinicians rule out vision and hearing problems, behavioral disorders, and ADHD(which is often comorbid).Early identification: Reading at two standard deviations below population mean signifies an especially poor outlook. when treated at age 7 could read normally by age 14. parent's edu level and child's overall intellectual capabilities need to be considered.2. Mathematics(Dyscalculia): Persons have difficulty performing mathematical operations(number sense, memorization of arithmetic facts, accurate or fluent calculations, or accurate math reasoning)--as simple addition or as complex as story problems--not know the cause.It could be part of a larger nonverbal learning disability or a problem in making a connection between number sense and the representation of numbers.5% school age are affected. Gerstmann's syndrome is acollection of sxs that results from a stroke or other damage to the left parietal lobe of the brain in the region of the angular gyrus.3. Written Expression: problems with grammar, punctuation, spelling, and developing their ideas in writing. Children have problems translating ideas from oral/auditory form to visual/written form; what they write may be too simple, too brief, or too hard to follow. Some have trouble generating new ideas. Handwriting may be indecipherable, yet you wouldn't make diagnosis when poor penmanship is the only problem.Problem usually doesn't appear until 2nd grade or later--after onset of reading learning disorder. Writing demands increase from third to sixth grade. It can be due to troubles with working memory(there's a problem with the organization of what the child is trying to say). The dx is generally not appropriate if px is poorly coordinated, as in developmental coordination disorder. -For each specify Severity:mild(some problems, but often with support the patient can compensate well enough to succeed), moderate(marked difficulties, these will require considerable remediation for proficiency. some accommodation may be needed),& severe(critical problems will be difficult to overcome without intensive remediation. Even extensive supportive services may not promote adequate compensation)\*\*School records of impairment can be used instead of testing for someone 17+ years
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Describe Differential Dx for Specific Learning Disorder
physical disorders such as vision, hearing or motor performance; intellectual disability; ADHD
30
What is a delusion?
A Delusion is a false belief that cannot be explained by the patient's culture or education; the patient cannot be persuaded that the belief is incorrect, despite evidence to the contrary or the weight of opinion of other people. Many types of delusions(erotomanic-in love w/px of higher status; grandeur-px is God or movie star; guilt-px committed an unpardonable sin or grave error; jealousy-spouse or partner unfaithful; persecution-px being followed, interfered with;poverty-px faces destitution; reference-px being talked about in press or tv; somatic-px body functions altered-they smell bad or have terrible disease; thought control-other's putting ideas into px's minds.Delusions must be distinguished from Overvalued ideas, which are beliefs that are not clearly false but continue to be held despite lack of proof that they are correct.EX:belief in superiority of one's race or political party.
31
What is a hallucination?
A hallucination is a false sensory perception that occurs in the absence of a related sensory stimulus. Hallucinations are nearly always abnormal and can affect any of the five senses, though auditory and visual hallucinations most common. But they don't always mean that the person experiencing them is psychotic.To count as psychotic sxs, hallucinations must occur when a person is awake and fully alert. Ex: during delirium does not count or when someone is experiencing falling asleep(hypnagogic) or awakening(hypnopompic). These experiences are normal and not true hallucinations, they are referred as imagery. Another requirement for a psychotic sx is that a person must lack insight into its unreality.EX: Charles Bonnet syndrome, in which people who have significant loss of vision see complex visual imagery-but with full realization that the experience is unreal.Hallucinations must be discriminated from ILLUSIONS, which are simply misinterpretations of actual sensory stimuli. They usually occur during conditions of decreased sensory input, such as at night. EX:impression in dark pile of clothes is burglar when turn on lights it's pile of clothes.Illusions are common and normal.
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What is disorganized speech?
Disorganized speech(loose associations) mental associations are governed not by logic but by rhymes, puns, and other rules not apparent to the observer, or by evident rule at all. Speech must be so badly impaired that it interferes with communication.
33
What is disorganized behavior?
Disorganized behavior or physical actions that do not appear to be goal-directed disrobing in public, repeatedly making the sign of the cross, assuming and maintaining peculiar and often uncomfortable postures--may indicate psychosis.
34
What are negative symptoms?
Negative sxs include reduced range of expression of emotion (flat or blunted affect), markedly reduced amount or fluency of speech, and loss of the will to do things(avolition). Negative sxs give the impression that something has been taken away from the px. Negative sxs reduce the apparent textural richness of a patient's personality. However, they can be hard to differentiate from the dullness due to depression, drug use, or ordinary lack of interest.
35
What are the 5 symptoms that are needed to determine psychotic disorder?
1. Delusions2. Disorganized speech3. Disorganized Behavior4. Negative Symptoms5. Hallucinations
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What are the four things to consider when diagnosing DSM-5 various types of psychosis?
1. type of psychotic symptom(delusions, disorganized speech and behavior, negative symptoms, hallucinations)2. course of illness (duration-at least 6 months for schizophrenia; precipitating factors-severe emotional stress-brief period of psychosis vs. stress of childbirth postpartum psychosis; previous course of illness-hx of complete recovery from psychosis suggests a disorder other than schizophrenia; premorbid personality-good social and job related functioning before the onset of psychosis directs diagnostic focus away from schizophrenia and toward another psychotic disorder such as depression or psychosis due to another medical condition or substance use; residual symptoms-once acute psychotic sxs treated, residual sxs may persist.often milder manifestations of person's earlier delusions or active psychotic sxs:odd beliefs, vague speech that wanders off the point. Return of psychosis.3. consequences of illness-affect functioning of px and family. Px w/schizophrenia must have materially impaired social or occupational functioning.Other dx not require this criterion for dx.Ex: Delusional disorder specifies that functioning is not impaired in any way except that it relates to delusions.4. exclusions-once fact of psychosis established, differential dx of physical conditions ruled out. History, physical examination and lab testing.Then substance-related disorders ruled out.History of px using cocaine, alcohol, psychostimulants, and psychotomimetics, that can cause psychotic sxs that closely mimic schizophrenia. The use of prescription medications(such as adrenocorticosteroids) can also produce sxs pf psychosis. Finally, consider mood disorders-mania or depression? History of mental health treatment as some pxs with mood disorders have been diagnosed as schizphrenia.5.Other Features: Family History of illness-A close relative w/schizophrenia increases your px chances of also having schizophrenia.Bipolar I also runs in families.More fam. HxResponse to medication-Regardless of how psychotic the px appears, previous recovery with, a medication, ex:lithium, tx suggestes a dx of mood disorder.Age at onset-Schizophrenia usually begins by a person's mid-20's. Onset of illness after the age of 40 suggests some other dx. It could be delusional disorder but should consider a mood disorder. Late onset does not rule out schizophrenia.
37
Essential features of Schizophrenia and differential diagnosis
1. 3-6years before becoming ill(prodromal period)-characterized by abnormalities of thought, language, perception, and motor behavior2.At least 6 months behavior changes-delusions and hallucinations may start or disorganized speech/behavior(catatonia)--at least two of the symptoms for at least a month and illness causes problems in work and social functioning.3. Clinician excludes other medical disorders, substance use, and mood disorders as probable causes.4. Check sxs for frequency, chronicity, severity, management in terms of cognitive dysfunction, dysphoria(anger, anxiety, depression), absence of insight of illness, sleep disturbance, substance use, suicide.Differential Dx: other psychotic disorders, mood, cognitive disorders, physical and substance induced psychotic disorders, or peculiar ideas --political or religious--shared by a community \*\*Can use Severity dimensional continuum and rate each level from 0 to 5. optional
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Schizophrenia and Schizophrenia-Like Disorders Summary List
1. Schizophrenia. For at least 6 months, these pxs have had 2 or more of the 5 types of psychotic sxs:delusions, disorganized speech, hallucinations, negative sxs, and disorganized behavior (catatonia). One of which has to be either delusion, hallucination, or disorganized speech. Ruled out as causes of the psychotic sxs are significant mood disorders are significant mood disorders, substance use, and general medical conditions.2. Catatonia associated with another mental disorder(catatonia specifier). These pxs have 2 or more of several behavioral characteristics (stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, and echopraxia). The specifier can be applied to disorders that include psychosis, mood disorders, autistic spectrum disorder, and other medical conditions.3. Schizophreniform disorder. This category is for pxs who have the basic sxs of schizphrenia but have been ill for only 1-6months--less than the time specified for schizophrenia.4. Schizoaffective disorder. For at least 1 month, these patients have had basic schizophrenia sxs; at the same time, they have prominent symptoms of mania or depression.5. Brief psychotic disorder. These pxs will have had at least one of the basic psychotic sxs for less than 1 month.
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Essential features of Schizophreniform Disorder and Differential Dx
Relatively rapid onset and offset. Young person (late teens or 20s) who for 30 days to 6 months has (1) delusions(especially persecutory) and (2) hallucinations (especially auditory). However, some pxs will have (3) speech that is incoherent or otherwise disorganized, (4) severely abnormal psychomotor behavior(catatonic symptoms, or (5) negative symptoms such as restricted affect or lack of volition (lack motivation to do work or family life). Diagnosis requires at least 2 of these 5 types of psychotic symptoms, at least one of which must be delusions, hallucinations, or disorganized speech. The patient recovers fully within 6 months.Differential Dx: physical and substance-induced psychotic disorders, schizophrenia, mood disorders, or cognitive disorders.Specify: With or Without good prognostic features.\*If it's still within 6 months and px is still ill use specifier (provisional). Once the px has fully recovered then remove the specifier. If still ill after 6 months, then change dx to schizophrenia or some other disorder. May specify severity but not have to.
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Essential features of Brief Psychotic Disorder and Differential Dx
All within a course of a single month, the px develops, then recovers completely from an episode of psychosis that includes delusions, hallucinations, or disorganized speech(disorganized behavior may also be present). The episode lasts at least 1 day but less than 1 month.Differential dx: mood or cognitive disorders, psychoses caused by medical conditions or substance use, schizophrenia\*If you make the diagnosis without waiting for recovery, you'll have to append the term (provisional)\*Can specify: With postpartum onset.Sxs begin within 4 weeks of giving birth.With or Without marked stressors. Stressors must appear to cause the sxs, must occur shortly before their onset, and must be severe enough that nearly anyone of that culture would feel markedly stressed.Can specify severity not have to.prevalence two fold in females than malesmay appear in adolescence and early adulthood and onset can occur across the lifespan, average age onset mid 30s. Preexisting personality disorders and traits (schizotypal, borderline personality disorder or traits in the psychoticism domain perceptual dysregulation and negative affectivity domain such as suspiciousness) may predispose the individual to the development of the disorder.
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Essential features of Delusional Disorder and Differential Dx
For at least a month, the px has had delusions but no other psychotic symptoms and any mood symptoms are relatively brief. Other than the consequences of the delusions, behavior isn't much affected(not bizzare or odd).Can be believeable and not have to be bizarre. There might be some hallucinations of touch or smell BUT only as they relate to the delusions. And they won't be prominent.Duration is 1month or longer. Distress and diability-None, except as related to the delusional content.Differential dx: physical and substance-induced psychotic disorders(ex:amphetamine-induced psychotic disorder with onset during withdrawal), mood (assess chronology and severity of mood sxs if any develop either before or after delusion sxs-if secondary to delusions-Need info from third parties like relatives to determine which came first.Mood sxs must be relatively mild and brief to sustain a dx of delusional disorder) or cognitive disorders(ex:dementia w/delusions), schizophrenia, obsessive-compulsive disorderCan specify type of delusion: erotomanic, grandiose, jealous, persecutory, somatic, mixed, or unspecified.Specify if: With bizarre content.this denotes obviously improbable delusions(ex:stranger removed internal organs and replaced with someone else's organs without leaving scars)If delusion disorder lasted at least a year, specify course:first episode, currently in acute episodeFirst episode, currently in partial remissionFirst episode, currently in full remissionMultiple episodes, currently in acute episode''...partial remission''...full remissionContinuousUnspecified
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Essential features of Schizoaffective Disorder and Differential Daignosis
The mood sxs (Manic episode or Major depressive episode) are important in that they must be present during half of more of the total duration of the illness. \*\*The psychosis sxs(delusions and hallucinations) are important in that they must be present by THEMSELVES for at least 2 weeks.(Note criteria is silent on whether to count psychosis sxs that are present during the time that mood sxs have disappeared under tx). During this same continuos period, the px fulfills the criterion A requirement for schizophrenia without having a mood episode.Duration-a total of 1+monthsDifferential Dx: psychotic mood disorders, substance use, and physical disordersSpecify: Bipolar TypeDepressive typeIf lasted at least 1 year, specify course:First episode in acute episode....Multiple...ContinuousUnspecified-Higher incidence in females than malesHigher risk in first degree relatives who have schizophrenia, bipolar, or schizoaffective disorderOverdiagnoses of African Americans and Hispanics w/schizoaffective disorderSchizoaffective disorder is associated with social and occupational dysfunction but dysfunction is not a diagnostic criterion as it is for schizophrenia.
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Essential Features of Substance/Medication -Induced psychotic Disorder and Differential Dx
The use of some substances appears to have caused hallucinations or delusions (or both).Only make this dx when sxs are serious enough to justify clinical attention & they are worse than you'd expect from ordinary intoxication or withdrawal.Consider:1. Sxs begin soon after(or during)the use of substance or its withdrawal.2.They start after a px has begun use of a medication.3.The drug/medication is known to be capable of causing the sxs in question.4. Of course if your px has had a prior episode of the same sxs that did follow the use of the same substance, that's perhaps the best evidence of all.Distress or Disability-work/academic, social,occupation;Differential Dx: schizophrenia spectrum disorders, delusional disorder, ordinary substance intoxication or withdrawal, delirium Classes/names of Medications that can cause Mental DisordersAnalgesics: anxiety, mood, psychosis, deliriumAnesthetics:anx, mood, psychosis, deliriumAntianxiety agents: moodanticholinergics:anxiety, mood, psychosisanticonvulsants:anxiety, mood, psychosis, deliriumantidepressants:anx, mood, psychosis, deliriumantihistamines:anx, psychosis, deliriumantihypertensives/cardiovascular drugs: anx, mood, psychosis, deliriumantimicrobials:mood, psychosis, deliriumantiparkinsonian agents:anx, mood, psychosis, deliriumantipsychotics:anx, mood, deliriumantiulcer agents: moodbronchodialators:anx, deliriumchemotherapeutic agents:psychosiscorticosteroids:anx, mood, psychosis, deliriumdisulfiram(Antabuse):mood, psychosis Gastrointestinal agents:psychoses, deliriumHistamine agonist:deliriumImmunosuppressants:deliriumInsulin:AnxietyInterferon:anx,mood, psychosisLithium:anxietyMuscle relaxants:mood, psychosis, deliriumNSAIDs:psychosisOral contraceptives:anxiety, moodthyroid replacements:anxiety
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Essential features of Catatonia associated with another mental disorder (catatonia specifier)
The clinical picture os dominated by 3 or more of the following sxs:1. Stupor (no psychomotor activity;not actively relating to environment)2. Catalepsy(passive induction of a posture held against gravity)3. waxy flexibility(slight even resistance to positioning by examiner)4. Mustism(no or very little verbal response[exclude if known aphasia]5.Negativism(opposition or no response to instructions or external stimuli)6. Posturing(sponteneous and active maintenance of a posture against gravity)7. Mannerism(odd,circumstantial caricature of normal actions8. Stereotypy(repetitive, abnormally frequent,non-goal-directed movements9. Agitation,not influenced by external stimuli10. Grimacing11.Echolalia(mimicking another's speech)12. Echopraxia(mimicking another's movements)The px has prominent sxs of catatonia and can apply specifier to manic, hypomanic, or major depressive episodes, schizophrenia, schizophreniform, schizoaffective, brief psychotic and substance-induced psychotic disorders. It can even be used for autism spectrum disorder.
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Essential features of Catatonia associated with another medical condition (catatonia specifier)
A list of some medical conditions that can produce catatonic behavior includes: liver disease, strokes, epilepsy, uncommon disorders such as Wilson's disease (a defect of copper metabolism) and the inherited disease (autosomal dominant), tuberous sclerosis.Neurological and medical consultation is needed for labs and X-ray studies.Urine and blood screens for toxic substances or drugs of abuse need to be considered as well as MRI.A physical illness appears to have caused sxs of catatonia.Differential Dx: delirium or other cognitive disorder, schizophrenia spectrum disorders, psychotic mood disorder, OCD.Coding: Use name of the medical condition, record dx after you've coded the actual medical condtitionEX: D32.9[225.2] Cerebral meningioma, benign F06.1 [296.89] Catatonic disorder due to cerebral meningioma
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What are the 5 major requirements of a major depressive episode?
1. Quality of depressed mood(or loss of interest or pleasure)-mood lower than normal, "unhappy," or expressing sadness BUT some pxs experience changes in functioning, loss of pleasure in activities2. that has existed for a minimum period of time-for at least 2 weeks3. is accompanied by a required number of symptoms-depressed mood, loss of pleasure, loss of weight or appetite, sleep, fatigue, psychomotor retardation(speech or phyisical movements slowed, marked pause before answering a question or initiating an action), agitated, low-self-esteem, guilt, death wishes, suicidal ideas. These behaviors have to occur nearly everyday.4. had resulted in distress or disability-impair work or school performance, social life(withdrawal or discord) or some other area of functioning, including sex.5. violates none of the listed exclusions-regardless of teh severity or duration of sxs, Major depressive episode usually should not be diagnosed in the face of clinically important substance use or a general medical disorder that could cause the sxsDifferential dx:substance use or physical disordersChildren and adolescents may only feel or seem irritable not depressed20% adult women10%adult men experience major depressive episode
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What is a manic episode?
The classic triad of manic sxs consists of heightened self-esteem, increased motor activity, and pressured speech.occurs in 1% of all adults.Quality of mood-some pxs w/mild sxs enjoy good humor and laugh but when mania worsens becomes less cheerful and takes on a "driven" unfunny quality that is irritable; euphoria and irritability sometimes occur together.Must have sxs for a minimum of 1 week.This requirement helps to differentiate manic episode from hypomanic episode.Sxs-heightened self-esteem can become grandiose and delusional that delusions are keeping with euphoric mood and are called mood-congruent.Rested on little sleep, heightened activity which may be goal-directed and useful, lost judgment, rapid and pressured speech, flight of ideas, easily distractedImpairment-Typically problems with co-workers and strained relationships with friends, mania helps at first with increased energy increased productivity at work and school but as mania worsens px less able to focus. Sexual entanglements result in divorce, unwanted pregnancy. After episode resolved, guilt remain.Exclusions-General medical conditions such as hyperthyroidism can produce hyperactive behavior; pxs who misuse certain psychoactive substances (especially amphetamines) will appear speeded up and may report feeling strong, powerful, and euphoric.Differential Dx:Substance use and physical disorders, schizoaffective disorder, neurocognitive disorders, hypomanic episodes, cyclothymia)Can have the specifier WIth Mixed Features-"Microdepressions"Acute manic episode with brief episodes of depression.-Informants can clarify history if the substance use or mania came first.Informants can also give history about Catatonic sxs occurring during a manic episode and sometimes causing the episode to resemble schizophrenia...but a hx of acute onset and previous episodes with recovery can help clarify dx. Then the specifier with catatonic features may be indicated.Mania is a building block of bipolar I disorder
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What is a hypomanic episode?
Same Sxs as manic episode, especially those who have bipolar II.Quality of mood tends to be euphoric without the driven quality present in manic episode, though mood can instead be irritable. It is clearly different from the patient's usual nondepressed mood.Duration for a minimum of 4 days--a marginally shorter time requirement than that for manic episode.Sxs-change in mood(euphoria or irritability), px must have an increase in energy or activity level for at least 4 days.Then 3 sxs from list for at least 4 days. If px abnormal mood is irritable and not elevated, 4 sxs are required. Sleep may be brief and activity level may be increased sometimes to the point of agitation. Judgment deteriorates and may lead to consequences in work or finances or social life. Speech may be rapid and pressured; racing thoughts or flight of ideas may be noticeable; Easily becoming distracted can be a feature of hypomanic episode. Heightened self-esteem is never grandiose that it becomes delusional, and hypomanic pxs are never psychotic.Impairment-Lapses of judgment such as spending sprees and sexual indiscretions can occur in both manic and hypomanic episodes but by definition only a px who is truly manic will be seriously impaired.Rule out substance/medication-induced sxs, with mixed features if appropriateBuilding block of Bipolar II disorder and Bipolar I disorder
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Essentials Features of Major Depressive Disorder{Single Episode}{Recurrent}
The px has {one} {or more} major depressive episodes and no spontaneous episodes of mania or hypomania.-Two months or more without sxs must intervene for episodes to be counted as separate.MDD affects about 7% of general population, with females 2:1.Usually begins in the middle to late 20s but it can occur at any time of life from childhood to old age.Onset may be sudden to gradual. Although an episode can last on average from 6 to 9 months the range can be from weeks to years.Recovery varies also from person to person.Strongly hereditary; first degree relatives have a risk several times that of general population.Some pxs have single episode in their lifetime with no MDD; however some pxs have episode with MDD with half having another episode. If so, recurrent episodes then every 4 yrs, more increase likelihood of suicide attempts.Completion rates of pxs with MDD is 4%.25% of pxs with MDD will experience a manic or hypomanic episode and may change their dx to bipolar I or II disorder.
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Essential Features of Bipolar I Disorder
Cyclic mood disorder that includes at least One Manic Episode.Men and women equally affected1% of general adult population and strongly hereditaryFirst, to count as a Bipolar one episode, It must either represent a change of polarity(from major depressive to manic or hypomanic episode) or it must be separated from the previous episode by a normal mood that lasts at least 2 months. Second, a manic or hypomanic episode will occasionally seem to be precipitated by the tx of a depression.Antidepressant drugs, ECT, or bright light may cause a px to move rapidly from depression into a full-blown manic episode. Bipolar I disorder is defined by the occurrence of spontaneous depressions, manias, and hypomanias; therefore, any treatment-induced manic or hypomanic episode can only be used to make the dx of bipolar I (or bipolar II) condition if the sxs persist beyond the physiological effects of that tx. DSM-5 demand the full # of manic and hypomanic sxs, not just edginess or agitation that some pxs experience following tx of depression.Note: mood episodes must not be superimposed on psychotic disorders such as schizophrenia spectrum disorders.Males are more likely than females to have a first episode that is manic. If the first episode is hypomanic then the dx is bipolar II disorder. Both men and women equally affected by bipolar I disorder. Usually bipolar I pxs have depressive episodes and followed by a manic episode and then a less severe hypomanic episode.Bipolar I usually have most manic episodes and few depressive episodes these are group of pxs at higher risk for completing suicide.Older patients who develop a mania for the first time may have a comorbid neurological disorder. they may also have a higher mortality.-Unspecified Bipolar Disorder. versus a recurrent mania in other older adults with recurrent mania.Pxs of Bipolar I need careful interview of sxs of addiction to alcohol. Alcohol use is diagnosed as a comorbid disorder as many as 30%.
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Essential features for Bipolar II Disorder
The px has had at least one each of a major depressive episode and a hypomanic episode, BUT no manic episodes ever. Never requires hospitalization and never involves psychosis.Women may be more prone than men to develop bipolar II; fewer than 1% of general population are affected, though prevalence of adolescence may be higher. The peripartum period may precipitate an episode of hypomania. Comorbidity-anxiety and substance use disorders, exting disorders common in femalesBipolar II pxs are ill longer and spend more time in the depressive phase than bipolar I pxs. Bipolar II may be more likely to make impulsive suicide attempts.And not a few (in the 10% range) will eventually experience a full-blown manic episode.Distress or disability-work/educational, social, or personal impairment, but only for depressive episodes or for switches between episodesDifferential dx-Substance use and physical disorders, other bipolar disorders, major depressive disordersSpecify current or most recent episode as {hypomanic}{depressed}Choose any relevant specifiers, for most recent episode, you can mention severity, mild, moderate, severe-choice
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Essential features of Persistent Depressive Disorder(Dysthymia)
Depressed sxs persist most of the time for 2 years(they are never absent for longer than 2 months). Some pxs aren't even aware that they are depressed though others can see it. They will acknowledge sxs as: fatigue, problems with concentration or decision making, poor self-image, and feeling hopeless. Sleep and appetite can be either increased or decreased. They may meet full requirements for a major depressive episode but the concept of mania is foreign to them.For children and adolescents, mood may be irritable rather than depressed and time requirement is 1 year rather than 2 years.6% of adults have dysthymia, w/women about twice as often as men, late onset uncommon.Distress and disability-work/educational,social, or personal impairmentDifferential Dx-substance use, physical disorders, ordinary grief and sadness, adjustment to a long-standing stressor, bipolar disorders, major depressive disordersSpecify severitySpecify onset-early-before age 20late onset-begins at age 21 or laterSpecify--With pure dysthymic syndrome-not meet MDD criteriaWith persistent major depressive episode- does not meet criteria through preceding 2 yearsWith intermittent MD episodes,with current episodes.-meets MD criteria now, but at times hasn't.With intermittent major depressive episodes,without current episode. Has met major depressive criteria in the past, though doesn't currently.
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Essential features of Cyclothymia
Pxs are either elated or depressed but for the first couple of years, they do not fulfill the criteria for a manic, hypomanic or major depressive disorder. Dysphoric, occasionally shifting into hypomania for a day or so. Others can shift several times in a single say. Often presentation is mixed.Typically beginning gradually in adolescence or young adulthood, it affects 1% of general population. affects gender same but women seek out treatment more, usually when depressed.Once begun, it tends toward chronicity.Can't have dx of Cyclothymia simultaneously with bipolar or MDD.Duration-2years or more; children& adolescents 1 year+Impairment-distress or disability-work/edu,social, personalDifferential dx-substance use, physical disorders, other bipolar disorders
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Essential features of Premenstrual Dysphoric Disorder
20% of women in the reproductive age are affectedSevere form affects 7% of women often beginning in the teenage years, these sxs appear for perhaps a few days or a week before each menstrual cycle. Complaints: dysphoric mood, anxiety, anger, fatigue, trouble concentrating,loss of interest, feeling out of control, muscle pain, changes in appetite or sleep, sensitivity of breasts, weight gain, and abdominal swelling or distention. Shortly after menstruation begins, she snaps back to normal. Differentiation from major depressive episode and dysthymia relies on timing and duration.15% attempt suicideRisk factors for PDD include excessive weight, stress, and trauma(hx of abuse), genetic component. Comorbid are anxiety disorders, mood disorders, including bipolar conditions.Duration-for several days around menstrual periods, for most cycles during the past yearDistress or disability-social, occupational or personal impairmentDifferential Dx: Substance use-including hormone replacement therapy; physical disorders; major depressive disorder or dysthymia; ordinary grief/sadnessDSM5 says that dx can only be stated as (provisional) until you've obtained prospective ratings of two menstrual cycles.
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Essential features of Disruptive Mood Dysregulation Disorder
New in DSM5, dysruptive mood dysregulation disorder(DMDD) showcases extremes of childhood. Children ages 6 to 17 years of ageCriteria: Temper outbursts---screaming or actually attacking someone or something--that are inappropriate for the patient's age and stage of development. Between outbursts the child is angry, grumpy, or sad. Occurring consistently, overreacting to common stressor, no manic episodes frequency on average 3+ times a week for at least 12 months, never absent longer than 3 months, starting before age 10(dx can only be made from ages 6 to 17)Underlying persistent irritability observed in at least 2 out of 3 settings (home, school, peers)80% of children with DMDD also qualify for Oppositional Defiant Disorder but only diagnose DMDD.DMDD more common in boys.Alternative to Bipolar I disorder.Differential Dx:Substance use and physical disorders, major depressive disorder, bipolar disorders, oppositional defiant disorder, attention-deficit/hyperactivity disorder, behavioral outbursts consistent with developmental age
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Essential features of Panic Disoder
Unexpected panic attacks-fear, stark terror, begins suddenly and is accompanied by a variety of classic "fight or flight" sxs, plus chest pain, chills, feeling too hot, chocking, shortness of breath, rapid or irregular heartbeat, tingling or numbness, excessive perspiration, nausea, dizziness, and tremor. May feel unreal or be afraid that are losing their minds or dying. At least 4 somatic sensations are required.Worried that will have another panic attack;usually uncuedTypically begins during pxs early 20s, found in 1-4% of general adult population(10-11% for panic attacks in general)Common among women.Avoidance of places where attacks have occurred.Duration-1+monthsDifferential Dx:substance use and physical disorders, other anxiety disorders, mod and psychotic disorders,OCD,PTSD, actual dangerPanic attacks can occur in several Medical conditions such as actute myocardial infarction, low blood sugar, irregular heartbeat, mitral valve prolapse, temporal lose epilepsy, and a rare adrenal gland tumor called phenochromocytoma.Panic attacks also occur during intoxication with several psychoactive substances including amphetamines, marijuana, and caffeine. Note some pxs misuse alcohol and sedative drugs to reduce severity of panic attacks.
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Essential feature of Panic Attacks as a specifier for any mental disorder
Panic attacks can be used as a specifier for ANY mental disorder, anxiety or other mental disorder(depressive disoder, substance abuse,etc), and some medical conditions.There are limited sx attacks-fewer than 4 physical and/or cognitive sxs2 types of panic attacks:expected (obvious cue or trigger)and unexpected attacks(no obvious cue or trigger), one type of unexpected attack is Nocturnal attack-waking from sleep in a state of panic.Panic disorder has panic attacks as an integral sx listed in its criteria.Therefore, this specifier would not be used with the dx of panic dx.
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Essential features of Agoraphobia
Fear some people have of a situation or place where escape seems difficult or embarrassing or where help might be unavailable if anxiety sxs should occur. Open or public places such as theaters and crowded supermarkets qualify, so does travel from home. Persons with agoraphobia either avoid the feared place or situation entirely, or if they must confront it, suffer intense anxiety or require the presence of a companion.Agoraphobia usually involves such situations as being away from home; standing in a crowd; staying home alone; being on a brigde; or traveling by bus, car or train.Agoraphobia can develop rapidly within just a few weeks with or without panic attacks causing the px to avoid leaving home or participating in other activities.prevalence rates 1-2%, women more susceptible, onset in the teens or 20s, some have first sx at age 40. strongly heritable.Duration: 6+ monthsDisability/distress:work/edu, social, personal impairmentDifferential Dx: Substance use, physical disorders, other anx disorders, mood and psychotic disorders, OCD, PTSD, social and separation disorders, situational phobias, panic disorder Agoraphobia-the perceived danger emanates from the environmentvs.Social anxiety-fear comes from the relationship from other peopleSeparation Anxiety Disorder-fear of being left alone
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Essential features of Specific Phobia
A specific situation or thing habitually causes immediate, inordinate and unreasonable dread or anxiety that the px avoids it or endures it with much anxiety.Best recognized are phobias of animals, blood, heights, travel by plane, being closed in, and thunderstorms. The anxiety produced by exposure to one of these stimuli may take the form of a panic attack or of a more generalized sensation of anxiety, but it is always directed to something specific. The closer they are to feared stimuli the worse they feel. Usually px have more than one specific phobia. Px with specific phobias involving blood, injury or injection often experience what is called vasovagal response--this means that reduced heart rate and blood pressure actually do cause the patients to faint.Up to 10% of US adults have a specific phobia.Onset is usually in childhood or adolescence; onset of animal phobias begin early on. Women outnumber men 2:1.Duration: 6+monthsDistress/disability:work/edu, social or personal impairmentDifferential dx:substance use, physical disorders,agoraphobia,social anx disorder, separation anx disorder, mood and psychotic disorders, anorexia nervosa, OCD, PTSDSpecify:Animal type(snakes, spiders)Natural environment type(thunderstorms,heights)Blood-injection-injury-type(syringes,operations)BloodInjections and transfusionsOther medical careInjurySituational type(traveling by air, being closed in)Other type(situations where the person could vomit or choke; for children, loud noises or people wearing costumes)
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Essential Features of Social Anxiety
Inordinate anxiety is attached to circumstances where others could closely observe the px--public speaking or performing,eating or having a drink, writing, perhaps just speaking with another person, playing a musical instrument, chocking when eating in public, or using a urinal.Because these activities almost always provoke disproportionately fear of embarrassment or social rejection, the px avoids these situations or endures them with much anxiety.Px have noticeable physical sxs: blushing, hoarseness, tremor, and perspiration.Some may have panic attacks. Children may express anxiety by clinging, crying, freezing, shrinking, back, throwing tantrums, or refusing to speak.Occurrence ranges from 4-13% in lifetime, men outnumber women in tx settings, however in general population women predominate samples. Onset is middle teensSxs of Social Anxiety overlap with Avoidant Personality Disorder, however Avoidant personality disorder is more severe, both begin early, tend to last for years, some commonalities in family history. Social Anxiety is reported to have a genetic basis.Duration:6+months (for adults and children)For children, these "others" must include peers, not just adultsDistress/Disability:work/edu, social, personal impairmentDiff dx: sub use&physical disorders, anorexia nervosa, OCD, Avoidant Per Dis, Normal shyness, and other anx disorders-especially agoraphobia.Specify: Performance Only. The px fears public speaking or performing but not other situations.
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Taijin Kyofusho(e.g., in Japan and Korea) syndrome
characterized by social evaluative concerns, fulfilling criteria for social anxiety disorder(p.205, DSM-5) that are associated with the fear that the individual makes other people uncomfortable(e.g., "My gaze upsets people so they look away and avoid me"), a fear that is at times experienced with delusional intensity. This sx may be also found in non-Asian settings.Other presentations of taijin kyofusho may fulfill criteria for body dysmorphic disorder or delusional disorder.
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Essential Features of Selective Mutism Disorder
DSM-5 classifies it as an anxiety disorder that affects children during preschool years ages 2 to 4 years old. Despite speaking normally at other times, the px regularly doesn't speak in certain situations where speech is expected, such as in class.Note: The first month of a child's first year in school is often fraught with anxiety;exclude behaviors that occur during this time.Duration:1+ monthsDistress/disability:Social or work/academic impairmentDiff dx: unfamiliarity w/language to be used, a communication disorder such as stuttering, psychotic disorders, autism spectrum disorder, social anxiety disorderPrevalence 1 in 1,000, affects gender equallyFam hx pos. for social anx and selective mutismcomorbidity-separation anxiety and social anx, not tend to have externalizing disorders(Oppositional Def or Conduct Def Dis)
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Essential Features for Separation Anxiety Disorder
Fear what might happen to a parent or someone else important in their lives, these pxs resist being alone. They imagine the parent will die or become lost(or that they will) so that even the thought of separation can cause anxiety, nightmares, or perhaps vomiting spells or other physical complaints. They are reluctant to attend school, go out to work, or sleep away from home--even in their own beds.Duration:6+months in adults, though extreme sxs-such as total school refusal-could justify dx after a shorter duration; 4+ weeks in childrenDistress/disability: work/edu, social or personal impairmentDiff dx: mood disorders, other anx disorders, PTSDlifetime Prevalence 4% children; 6% adults12 month adult prevalence:2%When the onset is in childhood the condition is likely to remit; with later onset, sxs con't into adulthood and are more severe disability-wax and wane.Most adults and children also have other disorders(especially mood, anx, sub use disorders) though separation anx disorder is often the condition present the longest. Children with Separation Anx Disorder often have an adult parent of the same disorder, as with most anx disorders, there is a Strong genetic component.
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Essential Features of Generalized Anxiety Disorder
Hard to control, excessive worrying about a variety of issues---health, family problems, money, school, work---results in physical and mental complaints: muscle tension, restlessness, becoming easily tired and irritable, experiencing poor concentration, and trouble with insomnia.Duration: on most days for 6+monthsDistress/disability: work/edu, social, or personal impairmentDiff dx: substance use and physical disorders, mood disorders, other anxiety disorders, OCD, PTSD, realistic worrynervousness is low-key and chronic, no panic attacksOnset age 30, 9% of general adult population, women predominateGenetic factors.
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Essential features of Obsessive Compulsive Disorder
Px has distressing obsessions or compulsions (or both) that occupy so much of their time they interfere with accustomed routines.Obsessions are recurring, unwanted ideas that intrude into awareness;the px usually tries to suppress, disregard, or neutralize them.Compulsions are repeated physical(sometimes mental) behaviors that follow rules (or respond to obsessions) in an attempt to alleviate distress; the px may try to resist them. The behaviors are unreasonable,meaning that they don't have any realistic chance of helping the obsessional distress.Note: That a repeated thoughts can themselves sometimes be compulsions if their purpose is to reduce the obsessional anxiety.4 major Sx patterns:1.Fear of contamination which leads to 2.excessive handwashing3.Doubts lead to 4.excessive checking:the px returns to repeatedly to be sure something is turned off(cooktop)Obsessions about symmetry commonly occur(counting, putting things in order),and forbidden thoughts(sacrilegious ideas, sexual taboos).Distress or disability:Typically, the obsessions and/or compulsions occupy an hour a day or more or cause work/educational,social, or personal impairmentDiff dx: substance use and physical disorders, "normal" superstitions and rituals that don't actually cause distress or disability, depressive and psychotic disorders, anxiety and impulsive-control disorders, Tourett's disorder, obsessive-compulsive personality disorder. Comorbidity:2/3 experience MDD, 15% attempt suicide, women and men affected equally.prevalence 2% gen pop, higher in higher SES and individuals higher intelligence.Strong familial(risk for first degree relatives 12% about 6 times normal) at least part inherited. Onset in adolescence (males) or young adulthood(females).When it begins before puberty, compulsions may start first, often accompanied by tics and comorbid disorders.Specify degree of Insight:With good or fair insight. The px realizes that the OCD thoughts and behaviors are definitely (or probably) not true.With poor Insight. The px thinks the OCD concerns are probably trueWith absent insight/delusional beliefs. The px strongly believes that the OCD concerns are true.\*\*Note: Poor Insight indicates worse prognosis.Specify if:Tic related.The px has a lifetime hx of a chronic tic disorder
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Essential features for Posttraumatic Stress Disorder
\*\*Criteria is for Adults, adolescents, and children older than 6 years old.Something truly awful has happened. One px has been gravely injured or perhaps sexually abused; another has closely involved in the death or injury of someone else; a third has only learned that someone close experienced an accident or other violence,whereas emergency workers (police, firefighters) may be traumatized through repeated exposure.As a result, for many weeks or months these patients:Repeatedly relieve their event, perhaps in nightmares or upsetting dreams, perhaps in intrusive mental images or dissociative flashbacks. Some people respond to reminders of the event with physiological sensations (racing heart, shortness of breath) or emotional distress.Take steps to avoid horror:refusing to watch films or tv or read accounts of event, or pushing thoughts or memories out of consciousness-Turn downbeat in their thinking:with persistently negative moods, express gloomy thoughts "I'm useless". They lose interest in important activities and feel detached from other people. Some experience amnesia for aspects of the trauma;others become numb, feeling unable to love or experience joyExperience sxs of hyperarousal:irritability, escessive vigilance, trouble concentrating, insomnia, or an intensified startle responseSurvivors of severely traumatic events, overall lifetime prevalence of PTSD is 9%.Comorbidity-mood, anx, substance use disordersA new specifier reflects that in 12-14% of pxs, dissociation is important in the development and maintenance of PTSD sxs.Duration: \>1monthDistress/Disability:work/edu, social, personal impairmentDiff dx: substance use and physical disorders[especially traumatic brain injury], mood and anxiety disorders, normal reactions to stressful eventsSpecify:With delayed expression. sxs sufficient for dx didn't accumulate until at least 6 months after the eventWith dissociative sxs: Depersonalization. This indicates feelings of detachment, as though dreaming, from the pxs own mind or body Derealization. To the px, the surroundings seem distant, distorted, dreamlike, or unreal.
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Essential features of PTSD for Children 6 years and Younger
Criteria:Direct experience, witness(not just see on TV), Learn ofIntrusion sxs(at least 1/out of 5): memories, dreams, dissociative reactions, psychological distress, or physiological reactionsAvoidance/Negative emotions sxs(1/6): avoids memories, avoids external reminders, negative emotional state, social withdrawal, decreased positive emotionsPhysiological sxs (2/5): irritable/angry, hypervigilance, startle, poor concentration, sleep disturbanceDuration:\>1 month
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Essential Features of Acute Stress Disorder
Direct experience, witness, learning of an event, and repeat exposure (not just TV)All Sxs (9/14): memories, dreams, dissociative reactions, psychological distress or physiological reactions, avoids memories, avoids external reminders, altered sense of reality of self or surroundings, amnesia, no positive emotions, irritable/angry, hypervigilance, startle, poor concentration, sleep disturbanceDuration:3 days-1 month Distress/Disability:work/edu, social, personal impairmentDiff dx: substance use and physical disorders[especially traumatic brain injury], panic disorder,mood disorders, dissociative disorders, PTSD.
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Essential Features of Adjustment Disorder
A stressor causes someone to develop depression, anxiety, or behavioral sxs--but the response exceeds what you'd expect for most people in similar circumstances. After the stressor has ended, the sxs might drag on, but not longer than 6 more months.Duration: starts within 3 months of stressor's onset, stops within 6 months of stressor's end.Distress/disability: work/educational, social, or personal impairmentDiff dx: Substance use and physical disorders, mood and anxiety disorders, trauma-related disorders, somatic sx disorder, psychotic disorders, conduct and other behavior disorders, milder reactions to life'd stresses, normal bereavement
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Essential Features for Reactive Attachment Disorder
Adverse child care(abuse, neglect, caregiving insufficient or changed too frequently) has apparently caused a child to withdraw emotionally; the child neither seeks nor responds to soothing from an adult. Such children will habitually show little emotional or social response; far from having positive affect, they may experience periods of unprovoked irritability and sadness.The presumption of causality stems from the temporal relationship of the traumatic child care to the disturbed behavior.-Young infants withdraw from social contacts, appearing shy or distant. Inhibited children will resist separation by tantrums or desperate clinging. In several cases, infants may exhibit failure-to-thrive syndrome, with head circumference, length and weight hovering around the 3rd percentile on standard growth charts.Factors that indicate increased risk factors for RAD include being reared in an orphanage or other institution;protracted hospitalizations;multiple or frequent changes in caregivers; severe poverty, abuse(gamut of physical, emotional, or sexual); and a family riven by death, divorce, or discord. Complications associated with RAD include stunted physical growth, low self-esteem, delinquency, anger management issues, eating disorders, malnutrition, depression, anxiety, and later substance misuse.A constant, nourishing relationship with a sensitive caregiver is required to reestablish physical and emotional growth.Without it, conditions persist into adolescence.Demographics:Begins before age 5;child had developmental age of at least 9 months.Diff dx: Autism spectrum disorder; intellectual disability disorder, depressive disordersSpecify: Persistent. Sxs are present longer than 1 year. Severe. All Sxs are present at a high level of intensity.
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Essential Features for Disinhibited Social Engagement Disorder
Adverse child care(abuse, neglect, caregiving insufficient or changed too frequently) has apparently caused a child to become unreserved in interactions with strange adults. Such children, rather than showing typical first-acquaintance shyness, with little hesitance to leave with a strange adult; they don't "check-in" with familiar caregivers, and readily become excessively familiar. In so doing, they may cross normal cultural and social boundaries.The presumption of causality stems from the temporal relationship of the traumatic child care to the disturbed behavior. Demographics:child has developmental age of at least 9 months.Diff dx: Autism spectrum disorder; intellectual disability disorder, ADHDSpecify: Persistent. Sxs are present longer than 1 year. Severe. All Sxs are present at a high level of intensity.A child's response in DSED borders on the promiscuous. Small children eschew normal wariness and boldly approach strangers, instead of clinging they may instead appear indifferent to the departure of a parent, especially when the main caregiver is absent it is most notable.Factors that indicate increased risk factors for RAD include being reared in an orphanage or other institution;protracted hospitalizations;multiple or frequent changes in caregivers; severe poverty, abuse(gamut of physical, emotional, or sexual); and a family riven by death, divorce, or discord. Complications associated with RAD include stunted physical growth, low self-esteem, delinquency, anger management issues, eating disorders, malnutrition, depression, anxiety, and later substance misuse.A constant, nourishing relationship with a sensitive caregiver is required to reestablish physical and emotional growth.Without it, conditions persist into adolescence.
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Essential features of Depersonalization/Derealization Disorder
Defined as a sense of being cut off or detached from oneself. This feeling may be experienced as viewing one's own mental processes or behavior; some pxs feel as though they are in a dream. Repeated episodes of feeling in a dream and not account for another diagnosis then depersonalization disorder/derealization disorder(DDD).Derealization:a feeling that the exterior world is unreal or odd. Px may notice that the size and shape of objects has changed or that people seem robotic or even dead. Always the person retains insight that it is only a change in perception--that the world has remained the same.About hald of adults have had at least one such episode, the sxs must be persistent or recurrent and they must impair functioning or cause pretty significant distress.EX: derealization and depersonalization is one of the qualifying sxs for panic attack.Episodes of DDD are precipitated by stress, they begin and end suddenly.Onset: teens and early 20s.Chronic.Prevalence-1-2%, women and men equally affected.
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Essential Features for Dissociative Amnesia Disorder
An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.Pierre Janet recognized several patterns of forgetting:Localized(or circumscribed):The px has recall for none of the events occurred within a particular time frame, often during a calamity such as a wartime battle or a natural disaster.Selective: Certain portions of a time period,such as the birth of a child, have been forgotten. This type is less common.Less common are the following 3 types and these lead to a dissociative identity disorder:Generalized: All of the experiences during the patient's entire lifetime have been forgotten.Continuous: The patient forgets all events from a given time forward to the present. This is now extremely rare.Systematized: the px has forgotten certain classes of information such as that relating to family or to work.Onset:Dissociative Amnesia begins suddenly, usually following severe stress such as physical injury, guilt about an extramarital affair, abandonment by a spouse, or internal conflict over sexual issues.Sometimes px wonders aimlessly near home. Duration: minutes to years.After which amnesia ends abruptly with complete recovery of memory. In some individuals it may occur again perhaps more than once. Begins early adulthood, commonly in young woman, 1% or less of gen. pop. Pxs have reported childhood sexual trauma, without memory of actual abuse.A subtype of Dissociative Amnesia, Dissociative Fugue, the amnesic person suddenly journeys from home, following a severe stress such as marital strife, natural or human-made disaster. The individual may experience disorientation and a sense of perplexity. Some will assume a new identity and name, and for months may even work at a new occupation. Most instances, episode is brief, lasting hours or days. occasionally there may be outbursts of violence. Recovery is usually sudden, with subsequent amnesia for the episode. Note: change in code number if px has dissociative amnesia with dissociative fugeEX: F44.1[300.13] Dissociative amnesia, with dissociative fugeversus dissociative amnesia without dissociative fuge[300.12]
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Essential Features of Dissociative Identity Disorder (AKA multiple personality disorder)
A px appears to have at least 2 clearly individual personalities, each with unique attributes of mood, perception, recall, and control of thought and behvaior. The result: A person with memory gaps for personal information that common forgetfulness cannot begin to explain.Affecting up to 1% of gen pop, diagnosed by North America than in Europe. Most pxs are female, and many may have been sexually abused. Dissociative Identity Disorder tends toward chronicity, it may run in families, but genetic transmission is questioned.Religious posession states accepted in non-Western cultures.Child having an imaginary playmate not diagnosable with Dissociative Identity Disorder.Diff Dx: Sub use and physical disorders, mood and anx disorders, psychotic disorders, trauma- and stressor-related disorders, other dissociative disorders, religious posession states accepted non-Western cultures, childhood imaginary playmates/fantasy play.
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Essential Features of Somatic Symptom Disorder
Requires only One somatic sx, but it must cause distress or markedly impair the patient's functioning. (DSM-5 NO longer requires a psychological factor/consideration, only somatic)The classical px has a pattern of multiple physical and emotional sxs that can affect various(often many) areas of the body, including pain sxs, problems breathing or heartbeat, abdominal complaints, and/or menstrual disorders. Of course, conversion sxs (body dysfunctioning such as paralysis or blindness that has no anatomical or physiological cause) may also be encountered. Tx that usually helps sxs that are caused by actual physical disease is usually ineffective in the long run for these pxs.Somatic Sx Disorder begins early in life--teens or early 20s and lasts for many years-lifetime. Overlooked by healthcare professionals, condition affects 1% of all women, men less often. 7-8% of mental health clinic pxs, tends to run in families,--transmission is both genetic and environmental, with low SES and low education.Half or more of pxs with Somatic Sx Disorder have anxiety and mood sxs.Duration: 6+monthsDifferential Dx: Substance use and physical disorders, mood or anxiety disorders, psychotic disorders or stress disorders, dissociative disordersSpecify:With Predominant Pain. Px who complains mainly of pain. Usually chronic and severe. Common pain is lower back, head, pelvis, or temporomandibular joint. Pain doesn't wax and wane with time and doesn't diminish with distraction.Chronic pain pain interferes with cognition, causing people to have trouble with memory, concentration, and completing tasks. It is associated with depression, anxiety, and low self-esteem, sleep may be disturbed.May have Slower response to stimuli.Pain usually begins in the 30s or 40s., usually following an accident or physical illness.Often diagnosed more in women than men.As its duration extends, it often leads to increasing incapacity for work and social life, and sometimes to complete invalidism.Pain affects adults in gen pop as high as 30% in US. Keep in mind these facts: 1.Pain is subjective--individuals experience is differently.2. There is no gross anatomical pathology. 3. Measuring pain is hard.
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Essential Features of Illness Anxiety Disorder
Despite the absence of serious physical sxs, the px is inordinately concerned about being ill. High anxiety coupled with a low threshold for alarm yields recurring behaviors concerning health (seeking reassurance, checking over and over for physical signs). Some pxs cope instead by avoiding hospitals and medical appointments.Duration: 6+months, though the concerns may varyDiff Dx: Substance use and physical disorders, mood or anxiety disorders, psychotic or stress disorders, body dysmorphic disorder, somatic symptom disorderSpecify subtype:Care-seeking type. the px uses medical services more than normal.Care avoidant type. Due to heightened anxiety levels, the px avoids seeking medical care.Common-5% of gen pop, tends to begin in 20s or 30s, equally in men and women.
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Essential Features of DSM-5 Conversion Disorder(Functional Neurological Symptom Disorder)
Conversion Disorder sx is 1. a change in how the body functions when 2. no causative physical or physiological malfunctioning can be found. These sxs are often termed pseudoneurological and include one or more voluntary sensory or motor sx---with or without impaired consciousness.Conversion sxs usually don't conform to the anatomical pattern we'd expect for a condition with a well-defined physical cause.Prevalence: 1/3 of adults have had one such sx of conversion. In mental health pxs only diagnosed 1 in 10,000, young people, more common in women than men.uneducated and medically unsophisticated.The dx criteria does not require px to undergo any labs or tests, the only requirement is that the px must undergo a physical and neurological evaluation, the px sx cannot be explained by a known medical or neurological disease process.Specify: Acute Episode: Sxs have lasted under 6 mos.Persistent. Sxs have lasted 6+ monthsSpecify: {With}{Without} psychological stressor}Specify type of sx:With weakness or paralysis; with abnormal movement(tremor, dystonia, abnormal gait)with swallowing sxs(lump in throat); or with speech sx(loss of voice)With anethesia or sensory loss; or with special sensory sx(hallucinations or other disturbance of vision, hearing, smell) ex: blindness, double visionwith mixed sxs
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Essential Features of Psychological Factors Affecting Other Medical Conditions
A physical sx or illness is affected by a psychological or behavioral factor that precipitates, worsens, interferes with, or extends the patient's need for txDiff Dx: other mental disorders, such as panic disorder, mood disorders, other somatic sx and related disorders, PTSDSpecify current severity:mild.the factor increases medical riskmoderate. the factor worsens the medical condition.severe. It causes an ER visit or hospitalizationExtreme. it results in severe, life-endangering riskCode the name of the relevant medical condition firstNote: Use this Dx for situations when it is clear that the psychological factor is adversely influencing the course of the illness.EX: Maladaptive health behaviors. Weighing nearly 400 pounds, Tim knows that he should avoid sweetened drinks, but nearly every day his love of Big Gulps wins out.
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Essentials for Factitious Disorder Imposed on Self Imposed on Another
Factitious Disorder Imposed on Self or on AnotherFactitious means something artificial. To present a picture of someone who is ill, injured, or impaired, {the px}{another person,acting for the patient} feigns physical or mental sxs or signs of illness, or induces a disease or injury. This behavior occurs even without evident benefits (such as financial gain,revenge, or avoiding legal responsibility).Diff Dx:substance use and physical disorders, mood or anxiety disorders, psychotic disorders, trauma- or stress-related disorders, dissociative and cognitive disorders, malingering)Diagnose:Factitious disorder imposed on self. The perpetrator is also the px.Factitious disorder imposed on another. The perpetrator and victim are separate individuals. (the perpetrator receives the factitious disorder code; the victim receives a Z-code reflecting the abuse)For either type, specify:Single episode.Recurrent episodes.
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Essential Features for Anorexia Nervosa
These pxs are usually women who 1. eat so little to point of markedly reduced body weight, yet 2. remain fearful of obesity or weight gain and 3. have the distorted self-perception that they are fat.Other sxs are elaborations of maladaptive behaviors--food restriction, excessive exercise, and vomiting or other methods of purging. Although many female pxs stop menstruating, the absence of menses doesn't provide meaningful distinction so criteria dropped.Abnormal vital signs, lab values, test. Those who binge and then purge to maintain low weight tend to be older, to be sicker, and to have worse outcomes than those who restrict their intake.Affects under 1% of female population.rate of males is 1/3 of that. Common in adolescent and young adults, especially those who are figure skaters or gymnasts (women) or jockeys or long distance runners(men).The restricting type is more usual. The concordance rate is higher in identical twins than in fraternal twins, indicating a genetic underpinning.Subtype: specify type-applies to previous 3 monthsBinge-eating/purging type. The px has repeatedly purged(vomited;misused enemas,laxatives or diuretics) or eaten in binges.Restricting types. the px has not recently binged or purged.Based on Body Mass Index(BMI; kg/meter2), specify severity(level may be increased,depending on functional impairment). For adults, levels are as follows:Mild. BMI of 17 or moreModerate BMI of 16-17.Severe BMI of 15-16.Extreme BMI under 15Specify if:In partial remission. For what DSM-5 calls "a sustained remission", the px is no longer significantly underweight, but is still overly concerned about weight or still has misconceptions about weight/shape.In full remission. For "a sustained period," a px has met no criteria for anorexia nervosa
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Essential Features for Bulimia Nervosa
Px has lost control over eating, consuming in binges much more food than is normal for a similar time frame. Fasting, vomiting, extreme physical workouts, and the abuse of laxatives or other drugs may be used to control weight.Duration: Weekly for 3+ monthsOnset: late teens or early 20sSpecify:In partial remission.In full remission.Specify severity:Mild. 1-3 episodes/weekModerate. 4-7Severe.8-13Extreme.14+
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Essential Features of Binge-eating Disorder
A Px has lost control, consuming in binges much more food than is normal in a similar time frame. During a binge the patient will eat too fast, too much(until painfully full), yet in the absence of actual hunger. The bingeing causes guilt(sometimes, depression) and solitary dining (to avoid embarrassment), but it does NOT result in behaviors (such as vomiting and excessive exercise) designed to make up for overeating.Duration: Weekly for 3+ months Distress over eating behaviorDiff Dx: mood disorders, bulimia or anorexia nervosa, ordinary overweightSpecify if:In partial remission. For what DSM-5 calls "a sustained period" the px has eaten in binges less often than once a weekIn full remission. For "a sustained period" the px has met no criteria for binge-eating disorder Specify severity:Mild.1-3binges/weekModerate.4-7.Severe.8-13.Extreme.14+Onset:teens or early 20s, sometimes on the heels of a diet.Affecting 2% of adults, and half that many adolescents.Occurs twice as many in women than in men.Prevalent in type 2 diabetes.often associated with obesity, 1/4 of px are overweight.The eating typically occurs when the person is feeling glum or anxious and often involve foods high in fat, sugar, salt, and guilt. Rapid eating until too much has been consumed and leading to uncomfortable and feeling too full.Binge eating may occur secretly as a consequence of shame and embarrassment, which contribute even more to distress and problems with quality of life than does the simple fact of obesity.
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Essential Features of Pica
The px persists to eating dirt or something else that isn't food.Duration: 1+months in someone who is at least 2 years old.Diff dx: nutritional deficits, deveomentally normal behavior, psychotic disorders, practice endorsed by the person's cultureSpecify if: In remission.Code by px's age:Pica in childrenPica in adultsPica is commonly reported in children and pregnant women. Dirt, chalk, plaster, soap, paper, and even feces.EX: One px from India consumed iron nails and glass beads. Pica has been associated with iron deficiency, and other minerals (zinc).Pxs with autism spectrum disorder and intellectual disability are prone to pica. Onset begins at 2 years old and remits during adolescence or when iron or mineral deficiency is corrected. It is traditionally associated with pregnancy .02% of pregnant Danish women but also found in px with schizophrenia.Px with gastroinstestinal blood loss that led to iron-deficiency anemia and Pagophagia(ice craving) among px with iron deficiency.
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Essentials for Rumination Disorder
During Rumination, an individual regurgitates a bolus of food from the stomach and chews it again. This occurs by the mechanism of retrograde peristalsis and it is a normal part of the digestive process of cattle, deer, and giraffes--they are ruminants. But humans it is abnormal and problematic. It develops when infants after they begin eating solid foods. Boys are often affected than are girls.Most people who ruminate will later reswallow the food. Some, however, especially infants and those with intellectual disability--instead spit it out, risking malnutrition, failure to thrive (in infants), and vulnerability to disease. Mortality rates as high as 25% have been reported. Rumination Disorder underdiagnosed for years perhaps because never asked.Cause is unknown.Theories:GERD, psychological-reflect disordered mother-baby relationship, and behavioral-reinforced by attention it attracts.Pxs with intellectual disabilities who live in institutions 6-10% are affected. Duration:1+months, at least several times/week, dailyDiff dx: physical disorders, intellectual disability, other eating disordersNot require harm, distress, impairment in functioning to px or to other people.Not separate behavior from normal and abnormal.
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Essential Features of Avoidant/Restrictive Food Intake Disoder
With no abnormality of self-image, the patient eats too little to maintain adequate nutrition or weight (for children, to grow or gain weight). As a result, the px may need tube feeding or added nourishment. Social and personal life may also be disrupted.3 categories of Avoidant/Restrictive Food Intake Disordered eaters:1. don't care about eating2. those who restrict their diet due to sensory issues (certain foods are just unappetizing), and 3.those who don't eat because of an unpleasant experience(perhaps the've choked when trying to swallow).Most of these eaters are under the age of 6, but could even be an adult.Diff Dx:medical conditions, accepted cultural practices, unavailability of food, mood or anxiety disorders, anorexia nervosa, psychotic or factitious disorders.
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Essential Features of Enuresis
Without known cause, the px urinates into clothing or bedding. At the age of 5 years or later, there is repeated voiding or uringe, it can be voluntary or involuntary. By a ratio of 4:1 primary enuresis(the child has never been dry) is more common than secondary enuresis. It is limited to bedwetting;daytime bladder control is unaffected.In some children, enuresis is associated with non-rapid eye movement sleep which occurs during the first 3 hrs of sleep. In others, trauma, such as hospitalizations or separation from parents may precipitate secondary enuresis which can occur more than once per night or randomly throughout the period of sleep. Strong genetic ties: 3/4 of affected children have first degree relative with a hx of enuresis. Having 2 enuretic parents strongly predicts that a child will be affected. Before age6, boys and girls will be equally affected.In older children boys are affected more.prevalence 1% in adolescence. Adults who wet bed are likely to continue doing so lifelong. Duration: 2+times/week for 3+months in someone 5 years of age or olderDistress or frequency as aboveDiff dx: medication side effects and physical disordersSpecify type:Nocturnal onlyDiurnal onlyNocturnal and diurnal
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Essential Features for Encopresis
The Px recurrently defecates in improper locations or in clothes.Duration: 1+times/month for 3+months in someone 4 years or olderDiff dx: laxative use and physical disordersSpecify type:With constipation and overflow incontinenceWithout constipation and overflow incontinence (less common type involves secrecy and denial. children hide their normal stools in unusual locations--behind the toilet, in bureau drawers--and then claim not to know how they got there.It's often associated with stress and family psychopathology.Some of these children may have been abused physically or sexually).Encopresis affects about 1% of elementary school age children, boys predominate by a 6:1 ratio.
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Essential Features of Insomnia Disorder
Insomnia is found in older patients and women.Distress: Daytime sleepiness at work, reduced effectiveness at work, interpersonal conflict at home, daytime fatigue, and sleepiness. Anyone who reports difficulty sleeping BUT does not report distress or disability should NOT receive a dx of Insomnia Disorder.10% of gen adult pop affected, more common in women than in men.It's mainly quality or amount of sleep that causes complaint:trouble getting to sleep, staying asleep, or awakening too early without again falling asleep. Occasionally, sleep is just plain not refreshing. The following day, the px feels fatigued, grumpy, or has poor concentration or otherwise impaired functioning.Duration: 3+ nights a week for 3+monthsDistress or disability: work/edu, social, or personal impairmentDiff dx: sub use and physical disorders, mood or anx disorders, psychotic disorders, PTSD, other sleep-wake disorders, poor sleep hygiene, or too little available sleep timeSpecify if:Episodic. Duration 1-3 months (any shorter-duration insomnia disorder would actually have to be coded as other specified insomnia disorder)Persistent.Duration 3+monthsRecurrent.2+episodes in 1 year
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Essential Features of Hypersomnolence Disorder
Excessive sleep or less than optimal quality of wakefulness--Trouble waking up or remaining fully awake, sometimes called sleep inertia-the sensation of just not being able to fully awaken (or stay that way) when we need to be fully alert.Px tend to fall asleep easily and rapidly(often 5 minutes or less) and they may sleep late the next day. total sleep time is likely to be 9 hrs or more in 24 hrs., they may feel so chronically tired and sleepy even after a normal night's sleep they take daytime naps.These tend to be long and unrefreshing.Have trouble awakening in the morning and may be groggy and have peculiar problems with disorientation, memory, and alertness. They may behave automatically, performing behaviors for which they have poor later recall.Onset:teens or 20s, affects females and males equally, 1% gen pop.Should NOT diagnose if it occurs ONLY with another sleep-wake disorderDuration: 3+times a week for 3+monthsDistress or disablity: work/edu, social, personal impairmentDiff dx: substance use and physical disorders, other sleep-wake or mental disorders, normal sleepSpecify if:Acute. Duration under 1 month.Subacute. Duration 1-3 months.Persistent. Duration 3+months.Specify if:With mental disorder.With medical condition.With another sleep disorder. Don't make the dx at all if hypersomnolence occurs only with another sleep disorderIn each case, code the coexisting disorder.Specify severity, depending on number of days w/difficulty maintaining daytime alertness.Mild.1-2 days a week.Moderate. 3-4 days a weekSevere. 5+ days a week
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Essential features of Narcolepsy
The px cannot resist attacks of daytime sleep, which are associated with cataplexy(Greek "to strike down"; it is a brief--usually 2 minutes or less), low cerebrospinal fluid hypocretin, and decreased REM sleep latency on nighttime polysomnography. Cataplexy is usually associated with strong emotion, such as laughter.The neuropeptide hypocretin (orexin) implicated and production in lateral hypothalamus as it promotes wakefulness. Pxs with narcolepsy often have much less of it than normal because neurons have destroyed by autoimmune process. Strongly hereditary, affects males and females equally, affects 1 person in 2,000. Onset: child or adolescent but nearly always by age 30.Can lead to depression, impotence, trouble at work, and accidents in street or on the job. Complications are weight gain and misuse of substances in attempt to keep awake.Mood disorders and generalized anx disorder sometimes comorbid.Duration: several times a month for 3+monthsDiff Dx: sub use and physical disorders, mood disorders, sleep apneaSpecify: Narcolepsy without cataplexy but with hypocretin deficiency''....without hypocretin deficiency (rare)Autosomal dominant cerebral ataxia,deafness,and narcolepsy; or autosomal narcolepsy,obesity, and type 2 diabetesNarcolepsy secondary to another medical conditionOther specified sleep-wake disorder;Narcolepsy with cataplexy with hypocretin deficiency; or other specified sleep-wake disorder; Narcolepsy with cataplexy with unknown hypocretin statusMild.Catalplexy under once a week;only 1-2 naps per day.Moderate. Cataplexy 1-7 times per week; multiple naps per day, troubled nighttime sleepSevere. Cataplexy that is resistant to medications; multiple attacks per day, troubled nighttime sleepcataplexy(Greek "to strike down"; it is a brief--usually 2 minutes or less)Catalepsy ("to hold down")is the prolonged form of immobility that occurs in catatonia.Hypnagogic and hypnopompic are terms to describe events that take place when one is going to sleep or waking up, respectively. "hypn="sleep" agogue= "leader," pomp= "sending away."
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Essential Features of Obstructive Sleep Apnea Hypopnea
A Px complains of daytime sleepiness that results from nighttime breathing problems:(often long) pauses in breathing, followed by loud snores or snorts. Polysomnography reveals obstructive apneas and hypopneas.Dx requires at least 5 apneas per hr, unless the hx reveals no nocturnal breathing sxs or daytime sleepiness; then, there must be 15 apnea/hypopnea episodes per hr.Mild.Fewer than 15 apneas/hypopneasModerate.
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Essential Features of Central Sleep Apnea
For each hour of sleep, the px's polysomnography shows 5+ central sleep apneas.Diff dx: other sleep wake disordersSpecify:Idiopathic central sleep apneaCheyne-Stokes breathing(a pattern of rising and falling depth of breathing, with frequent arousals)Central sleep apnea comorbid with opioid useCode severity based on number of apneas/hypopneas per hr and degree of oxygen saturation and sleep fragmentation. DSM-5 doesn't provide any further guidelines.
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Essential Features of Sleep-Related Hypoventilation
A px's polysomnography shows periods of reduced breathing and high CO2 levels. Normal=oxygen (O2) high, means 95% or higher; carbon dioxide (CO2) just right--range 23-29 milliequivalents per liter. Our bodies accomplish this by means of a simple feedback loop: Low Oxygen or high carbon dioxide signals the brain's respiratory center that our lungs need to work harder. In people with sleep-related hypoventilation, the chemoreceptors and the medullary(brainstem) neuronal network fail to send the right sort of signal, so breathing remains shallow. When awake, these folks compensate by intentionally breathing faster or deeper, but during sleep that strategy fails and breathing becomes shallower still. Sxs are usually worse during sleep and periods of apnea, when breathing stops completely, usually occur.Found in people severely overweight or individuals who have disorders such as muscular dystrophy, poliomyelitis, amyotrophic lateral sclerosis, and tumors, and other lesions of the spinal or central nervous system. Most adult pxs usually men ages 20-50 don't complain of breathing problems but of daytime drowsiness, fatigue, morning headache, frequent nocturnal awakenings, and unrefreshing sleep. They may also have ankle edema and blue skin tone that indicates oxygen deficit. Even small doses of sedatives or narcotics can make already inadequate breathing much worse. It can affect small children too (chromosome 4autosomal dominant gene-child born without breathing..some survived with mechanical assisted breathing into adulthood).Despite clues of daytime sleepiness, fatigue, and morning headaches, DSM-5 criteria rests entirely on results of polysomnography. The syndrome is uncommon.
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Essential Features of Circadian Rhythm Sleep-Wake Disorders
The word circadian comes from the Latin word "about 1 day." It refers to the body's cycles of sleep, temperature, and hormone production, which is generated in the suprachiasmatic nucleus of the brain's anterior hypothalamus.When there are no external time cues(natural daylight or artificial reminders like clocks), the free-running human cycle is actually about 24hours, 9 minutes. A misalignment between our natural body rhythms and the demands of work or social lives results in unwanted sleeplessness or drowsiness, or both.The normal circadian sleep-wake cycle changes throughout life. It lengthens during adolescence; that's one reason why adolescents are prone to late nights and sleeping in. It shortens in old age, causing older people to fall asleep in the evening while reading or watching TV and making both shift work and jet lag harder on them.5 Subtypes1.Circadian Rhythm Sleep-Wake Disorder, Delayed Sleep Phase Type: "Owls" or Night People"---go to sleep late(sometimes progressively later each night) and awaken in late morning or afternoon. Left in their own devices, they feel just fine. If get up early they feel drowsy and appear "sleep drunk". Irregular sleep habits and the use of caffeine or other stimulants only worsen their plight. Account for 10% of sleep clinic pxs who complain of chronic insomnia.Most common type.Common among teens and young adults.Estimated 3% older (ages 40-64) gen pop. A familial component in up to 40%.2. Circadian Rhythm Sleep-Wake Disorder, Advanced Sleep Phase Type: "Early to Bed, Early to Rise" disorder. Desire to sleep early and get sleepy in late afternoon or early evening. Sometimes they are called "larks." It causes less discomfort and fewer social problems. Occurs with advancing age and runs in families.3. Circadian Rhythm Sleep-Wake Disorder, Non-24-Hour Sleep-Wake Type: AKA Free-Running type and happens mainly in completely blind people, who of course have no light cues to entrain their biological clocks. (Up to 50% of blind people may be affected beginning at the age of total blindness begins; most of these with minimal light perception--even the equivalent of a single candle-remain normally entrained. Sighted people who are affected tend to be mainly young (teens and 20s) and male; they often have other mental disorders. The 18-hour schedules that accompany life in a submarine can also lead to a free-running biological rhythm. Most sighted people who undergo research protocol in which there is no visual cues will ultimately develop non-24hour sleep wake type.4. Circadian rhythm Sleep-Wake disorder, Irregular Sleep-Wake Type:No pattern. Sleep duration may be normal but they feel sleepy and insomniac at varying and unpredictable, times of day. They may take naps, so it's important to rule out poor sleep hygiene. Irregular type may be encountered in various neurological conditions, including demetia, intellectual disability, and traumatic brain injury. Prevalence unknown...probably rare. Affects sexes equally. Age is a risk factor, mainly due to the late-life presence of medical disorders such as Alzheimer's disease.5. Circadian Rhythm Sleep-Wake Disorder, Shift Work Type: When workers change from one shift to another when they must be active during their former sleep time, sleepiness sets in and performance declines. Sleep during the new sleep time is often disrupted and too brief. The sxs which can affect nearly a third of people doing shift work, are worst after a switch to night work, though people vary considerably in the time required for this adjustment. Additional factors include age, commuting distance, and whether the individual is naturally a "lark" or an "owl." Sxs may last 3 weeks or longer, especially if workers try to resume their normal sleeping schedules on weekends or holidays.
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Essential Features of Non-Rapid Eye Movement Sleep Arousal Disorders (Parasomnia-normal sleep achitecture but something abnormal hapens during sleep)
During non-REM sleep arousal disorders, pxs experience simultaneous sleeping and waking EEG patterns; sxs ensue. Partial arousals occur suddenly from non-REM sleep usually in the first hour or two of sleep, when slow-wave sleep is most prevalent. 3 main types of abnormal arousal: Confusional arousal
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Essential Features of Restless Leg Syndrome
Unpleasant leg sensations cause an impulse to move them, which tends to relieve sxs. Legs are restless in the evening or later.The tendency to delay the onset of sleep;sometimes it awakens the px during the night. It's associated with disturbed sleep and reduced sleep time. Relief can come in many disguises--walking, pacing, stretching, rubbing, even riding a stationary bike. The trouble is that each of these increases wakefulness. Besides causing the person to feel tired the next day, restlessleg syndrome can lead to depression and anxiety. It tends to lessen throughout the night allowing for more refreshing sleep toward morning. Overall, it worsens with time, though it may wax and wane over a period of weeks. It's been associated with MDD, GAD, PTSD, and Panic Disorder. Nobody knows why it occurs but it may be related to neurotransmitter dopamine. It's reported with pxs with Parkinson's disease whose basal ganglia are compromised. One quarter of pregnant women report it, especially in third trimester. It's found in neurological conditions such as neuropathy and multiple sclerosis, and in iron deficiency and renal failure. It can be exacerbated by medications such as antihistamines, antinausea preparations, mirtazapine(remeron), and some other antidepressants. The effects of mild obstructive sleep apnea can sometimes look like periodic limb movements. 2% of gen pop complain of resteless leg syndrome.1% of school age children.More frequent in European Americans and less in people of Asian descent; prevalence in women greater than men. Onset-Teens or 20s; Family hx sometimes found; Genetic markers have been identified; A simple interview enough to make dx.Problems: Restless leg syndrome has a delay sleep onset. it can awaken pxs during the night. It can result in daytime hypersomnolence--often causing distress or impaired funcntioning.Duration:3+times a week for 3+monthsDistress or disability: work, edu, social, or personal impairmentDiff Dx: sub use and physical disorders
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Essential Features of Nightmare Disorder
The px repeatedly awakens, instantly and completely, from terrible dreams that are recalled in frightening detail.When someone repeatedly has long, terrifying dreams of that sort, or suffers from daytime sleepiness, irritability, or loss of concentration, a dx of nightmare dx may be warranted.These occur during the latter part of the night, px wakens and remembers dreams.(versus non-REM sleep arousal disorder, sleep terror type which occurs in early part of non-REM sleep-poorly remembered dreams, and px wakens only partially). Withdrawal from REM-suppressing substances such as antidepressants, alcohol, or babiturates can sometimes increase the tendency to nightmares.Distress or disability: work, edu, social or personal impairmentDiff dx: substance use and physical disorders, non-REM arousal disorder; sleep terror disorder type; REM sleep behavior disorder; other mental disordersSpecify if: During Sleep onsetSpecify if:With associated non-sleep disorderWith associated other medical conditionWith associated other sleep disorderSpecify if:Acute. Has lasted less than 1 monthSubacute. Has lasted 1-6 monthsPersistent. has lasted 6+ monthsSpecify severity:Mild. Less than once a week.Moderate. 1-6 episodes per week.Severe. Every night.
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Essential Features of Rapid Eye Movement Sleep Behavior Disorder
The px has recurrent episodes of arousing from sleep accompanied by shouting or speech, or by physical actions that can injure the px or bed partner. These sxs often correlate with dream content. Subsequent awakenings tend to be complete. Because they occur during REM sleep, these episodes tend to take place after the person has been asleep quite a while, and not during naps.If the person has a typical hx as described above, together with a synucleinopathy (such as Parkinson's disease or Lewy body demetia) no polysomnography is necessary. Without this history, there must be polysomnography evidence of REM sleep with maintencance of muscle tone.Distress or disability: work, edu, social, or personal impairmentDiff dx: substance use and physical disorders, other sleep-wake disordersPx 80% are male. Onset usually after age 50. some children can be affected. Up to a third of pxs are unaware of their sxs and half don't recall their dreams. Over behavior may closely reflect their dream content and sometimes called "acting out their dreams." Although motor behaviors consist of mild twitches, they can escalate to sudden, punches, kicking, or even biting. Some pxs will talk, shout, laugh, swear, or cry. Overall prevalence of injury to self or others is over 90%.Overall condition affects 1% of of gen pop.Of these pxs, about half will have or develop one of these illnesses: Lewy body dementia, Parkinson's disease or multiple-system atrophy. These are collectively referred as synucleinopathies because their underlying cause is abnormal intracellular masses of the protein alpha-syncuclein.
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Essential Features of Substance/Medication-Induced Sleep Disorder
The use of some substances appears to have caused a px to have a serious sleep problem.EX:Alcohol. Heavy use (intoxication) can produce unrefreshing sleep with strong REM supression and reduced total sleep time. Px may experience terminal insomnia and sometimes hypersomnolence, and their sleep problems may persist for years. Alcohol withdrawal markedly increases sleep onset latency and produces restless sleep with frequent awakenings. pxs may experience delirium with tremor and (especially visual) hallucinations, this was known as delirium tremens.Sedatives, hypnotics, and anxiolytics. These include barbiturates, over-the-counter antihistamines and bromides, short-acting benzodiazepines, and high doses of long-acting benzodiazepines. Any of these substances may be used in the attempt to remedy insomnia of another origin. They can lead to sleep disorder during either intoxication or withdrawal.Central nervous system stimulants. Amphetamines and other stimulants typically cause increased latency of sleep onset, decreased REM sleep, and more awakenings. Once the drug is discontinued, hypersomnolence with restlessness and REM rebound dreams may ensue.Caffeine. This popular drug produces insomnia with intoxication and hypersomnolence upon withdrawal.Other drugs. These include tricyclic antidepressants, neuroleptics, ACTH, anticonvulsants, thyroid medications, marijuana, cocaine, LSD, opioids, PCP, and methyldopa.You'd only make this dx when the sxs are serious enough to warrant clinical attention and tehy are worse than you'd expect from ordinary intoxication or withdrawal.Specify:With Onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.With onset after medication use. You can use this in addition to other specifiers.Specify:Insomnia typeDaytime sleepiness typeParasomnia type (abnormal behavior when sleeping)Mixed type
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Essential features of Male Hypoactive Sexual Desire Disorder
A man lacks erotic thoughts or wishes for sexual activity.A clinician must judge the deficiency in light of age and other factors that can affect sexual function.Duration: 6+months Distress to pxDiff dx: Substance us and physical disorders, relationship problems, other mental disordersSpecify:{Lifelong}{Acquired}{Generalized}{Situational}Specify severity of distress over the sxs:{Mild}{Mod}{Severe}1994 survey of 1,400 men, 16% agreed they had a period of several months then they were not interested in sex.These men tended to be older, never married, not highly educated, black, and poor. Compared to other men, more likely to have been inappropriately touched before puberty, to have experienced homosexual activity at some time of their lives, and to use alcohol daily.Male Hypoactive Sexual Desire Disorder can be primary or acquired., the relative is less common.Primary type has been associated with some sort of sexual secret(such as shame about sexual orientation, past sexual trauma, perhaps a preference for masturbation over sex with a partner). Such a man's low sex desire may be masked by the effect of a new romance;this glow typically persists for only a matter of months before frustration and heartache(and more secrecy) set in, for px and partner alike.Acquired Male Hypoactive Sexual Desire Disorder is the more common pattern. It often develops as a consequence of dysfunction of erection or ejaculation (early or delayed). These in turn can stem from a variety of causes: diabetes, hypertension, substance use, mood or anxiety disorders, sometimes lack of intimacy with a partner.Whatever the origin, the man's confidence in his ability to achieve or maintain an erection (or to satisfy his partner) yields to a pattern of anticipatory anxiety and failure. He has trouble admitting that his sexual relationship is less than perfect, and so he retires from the fray so to speak, defeated and uncommunicative.Such a pattern can begin at almost any stage of life, though about two out of three couples stop having sex by their mid-70s. At any age, when this happens to heterosexual couples, it is overwhelmingly 90% likely to be the man's initiative.
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Essentials of Erectile Disorder
AKA Impotence, can be partial or complete. In either case, the erection is inadequate for satisfactory sex. Impotence can be situational, px can achieve an erection under certain circumstances(ex:prostitutes). Most prevalent male sexual disorder, occurring in 2% young men, not improve with age. Most likely to occur for the first time later in life.A variety of emotions can play a role in the development or maintenance of erectile disorder.These include fear, anxiety, anger, guilt, and distrust of sexual partner. Any of these feelings can preoccupy a man's attention that he cannot focus adequately on feeling sexual pleasure. Even a single failure may lead to anticipatory anxiety, which then precipitates another round in the circle of failure. Masters and Johnson talk about a factor called spectatoring, in which a px evaluates his performance so constantly that he cannot concentrate on the enjoyment of sex. Such a px may have an erection with foreplay but lose it upon penetration. Erection Disorder should not be diagnosed if biological factors are the principal or only cause. This is unlikely is erections occur spontaneously, with masturbation or with other partners. Some authorities now estimate that half or more of pxs who complain of impotence have a biological cause for it such as prostatectomy for cancer. When psychological factors are judged to be part of the cause, as is often the case, the dx can be made. It can be lifelong or acquired, the former is rare and hard to treat.The px almost always has marked trouble achieving or maintaining an erection adequate to consummate sex.Duration: 6+monthsDistress: to the pxDiff dx: substance use and physical disorders, relationship problems, other mental disordersSpecify:{Lifelong}{Acquired}{Generalized}{Situational}Specify severity of distress over the sxs: {Mild}{Mod}{Severe}
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Essential features of Premature (Early) Ejaculation
The man climaxes before he wants to-sometimes just as he and his partner reach the point of insertion. However different studies use widely varying standards of how many minutes actually constitutes early: 7 minutes? 1 minute? Whatever the duration, the climax yields disappointment and a sense of failure for both partners; secondary impotence sometimes follows. Stress in a relationship can exacerbate the condition, which of course promotes even greater loss of control. However, some women may value premature ejaculation because it decreases their exposure to unwanted sexual activity or pregnancy. About nearly half the men treated for sexual disorders have premature ejaculation. Common disorder. It is frequent among men with more education because of their partner satisfaction. Whereas anxiety is a factor, physical illness or abnormalities rarely cause this problem.Duration:6+ monthsDistress: patientDiff dx: substance use and physical disordersSpecify: {Lifelong}{Acquired}{generalized}{Situational}Specify severity:Mild. The px ejaculates 30-60 seconds after penetration.Moderate.15-30 seconds after penetration.Severe. 15 seconds after penetration or less (perhaps before penetration).
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Essential Features of Delayed Ejaculation
Men with Delayed Ejaculation achieve erection without difficulty but have problems reaching orgasm. Some only take a long time; others may not be able to ejaculate into a partner at all. Prolonged friction may cause the partners of these pxs to complain of soreness. Anxiety about performance may cause secondary impotence in the pxs themselves. Even when it has been present lifelong, a man can usually ejaculate by masturbation(alone or with the help of his sex partner). Px personalities with lifelong Delayed Ejaculation have been described as rigid and puritanical; some seem to equate sex with sin. The disorder may be acquired from interpersonal difficulties, fear of pregnancy, or a partner's lack of sexual allure. More common in px's with anxiety disorders. Delayed Ejaculation is uncommon, when men do have it there is often a medical cause.ex: hypoglycemia, prostatectomy, abdominal aortic surgery, Parkinson's disease, and spinal cord tumors. Some men have a physical abnormality that upon orgasm causes semen to be expelled into the urinary bladder(retrograde ejaculation). Drugs like alphamethyldopa (an antihypertensive) and thioridazine(a neuroleptic) as well as alcohol have been implicated. If any of these are factors then it cannot be dx as Delayed Ejaculation Disorder.Duration: 6+monthsDistress: to pxDiff dx: substance use and physical disorders, relationship problemsSpecify:{Lifelong}{Acquired}{Generalized}{Situational}Specify severity: Mild}{Mod}{Severe}
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Essential Features of Female Interest/Arousal Disorder
A woman's low sexual interest or arousal is indicated by minimal interest in sexual activity, erotic thoughts, response to partner overtures, and enjoyment during sex. She will generally not initiate sexual activity and doesn't "turn on" to erotic literature, movies, and the like.Duration: 6+ monthsDistress: to pxDiff Dx: Substance use and physical disorders, relationship problemsSpecify:{Lifelong}{Acquired}{Generalized}{Situational}Specify severity: Mild}{Mod}{Severe}Overlap in women between desire and arousal. Desire=cognitive component of arousal. One phase does not precede the other, their relationship depends on the individual. Treating desire also improves arousal. Sexual desire depends on several factors:px's inherent drive, self-esteem, previous sexual satisfaction, an available partner, and a good relationship w/the partner in areas other than sex. Sexual desire may be suppressed by long abstinence. It may present as infrequent sexual activity or as a perception that the partner is unattractive. Some pxs become averse to sex,expressing loathing to genital contact or aspects of genital sexual contact. Lack of interest in sex is the most common complaint of women in tx. About 30% of women ages 18-59 admit to having a period of at least several months when they've lacked sexual desire. Half feel distress, which affect the individuals or their relationships. Low desire is greater for women who are postmenopausal(either naturally or after surgery). There may be a hx of painful intercourse, feelings of guilt, or rape, or other sexual trauma occurring in childhood or earlier in px's sexual life. Don't dx Femanle Sexual Interest/Arousal Disorder if the problem occurs only in the context of another mental condition such as major depressive disorder or a substance use disorder. (Among the medications that can contribute are antihistamines and anticholinergics). Also, note that postmenopausal females may need more foreplay to lubricate to the same degree than they did when younger. However, Female Sexual Interest/Arousal Disorder often coexists with another sexual condition such as female orgasmic disorder. A woman who does not express interest in sex but does respond to sexual activity with excitement would not qualify for a dx. Neither would someone who identifies herself as having been "asexual" her whole life.
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Essential Features of Genito-Pelvic Pain/Penetration disorder
A px has major, repeated pain or other problems with efforts at vaginal intercourse; she may experience anxiety, fear, or pelvic muscle tensionDuration:6+monthsDistress: to pxDiff dx: substance use and physical disorders, relationship problemsSpecify:{Lifelong}{Acquired}{Generalized}{Situational}Specify severity: Mild}{Mod}{Severe}Cramping contraction of the vaginal muscles-vaginismusthat may be described as an ache, a twinge, or a sharp pain. Anxiety can produce tension in the pelvic floor, with resulting pain severe enough to prevent consummation of a relationship (sometimes for years). Soon anxiety comes to replace sexual enjoyment. Some pxs can't even use a tampon; a vaginal exam may require anesthesia.Nearly a third of women who have had gynecological surgery will experience some degree of pain w/intercorse. Infections, scars, and pelvic inflammatory disease have also been reported as causes. Don't dx when pain is only a sx of another medical condition or is due to substance misuse. % of women is unknown.
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Essential Features of Female Orgasmic Disorder
A woman has been troubled by orgasms that are too slow, too rare, or too weak30% of women report significant difficulties; 10% never learn the trick of having orgasm. A few physical illnesses, including hypothyroidism, diabetes, and structural damage to the vagina can contribute to the condition; if judged to be exclusively the cause, they obviate the dx to be female orgasmic disorder. Orgasm can also be inhibited by medications such as antihypertensives, central nervous stimulants, tricyclics antidepressants, and monoamine oxidase inhibitors. Possible psychological factors include fear of pregnancy, hostility of the px toward the partner, and feeling guilty about the sex in general. Age, previous sexual experience, and the adequacy of foreplay must also be considered in the dx. Once learned, a woman's ability to achieve orgasm persists, often improving throughout life. But women don't complain about having premature orgasms the way men do. Comorbid with female sexual interest/arousal disorder.Duration:6+monthsSpecify:Never experienced an orgasm under any situationSpecify:{Lifelong}{Acquired}{Generalized}{Situational}Specify severity: Mild}{Mod}{Severe}
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Essential Features of Gender Dysphoria in Adolescents or Adults, & In Children
Adolescents or AdultsThere is a marked disparity between norminal (natal) gender and what the px experiences as a sense of self. This can be expressed as a rejection or wish not to have one's own sex characteristics or to have those of the other gender. The px might also express the desire to belong to the other gender and to be treated as though that were the case. Some pxs believe that their responses are typical of the other gender.In ChildrenThe characteristics of Gender Dysphoria in children are similar to those in adults, but manifest themselves in age-appropriate ways. So, in their powerful longing to be opposite gender, kids may insist that's what they are; they prefer clothing, toys, games, playmates, and fantasy roles of the other gender while rejecting their own; and they may say they hate their own genitalia and want that which they don't have. Note that in children, the number of criteria required (six out of eight) is far greater than for adults(two out of six); this is a protective device for persons who have not yet fully matured.Duration: 6+months, regardless of ageDistress or disability: work,edu,social, or personal impairmentDiff dx: substance use and physical disorders, body dysmorphic disorder, and [in adolescents/adults] transvestic disorder.Specify if:With a disorder of sex development(and code the actual cogenital developmental disorder)Posttransition(for adolescents/adults).The px is living in the desired gender and has had at least one cross-gender surgical procedure or medical tx (such as hormone regimen).In gen pop. 1-2% of boys and smaller percentage of girls want to be other gender.Mainly boys referred to clinic about effeminate son than tomboy daughter. Although cross-gender behaviors often begin by age 3, the typical child isn't referred until yrs later.Boys prefer playing with dolls, asumming a female role in play, cross-dressing, and associating with peer group of girls. Girls take a male role in family games and reject female activities such as playing with dolls."persisters"--those who are still affected--girls to remain dysphoric from childhood into adulthood. It is more common for boys with gender dysphoria to grow up to become gay men than to have gender dysphoria; a minority become normally heterosexual; a few have Gender Dysphoria as adults. Females about under 50% of persisters into adulthood with Gender Dysphoria.
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Essential features of Oppositional Defiant Disorder
These pxs are often angry and irritable, tending toward touchiness and hair-trigger temper. They will disobey authority figures or argue with them, and they may refuse to cooperate or follow rules--if only to annoy. They sometimes accuse others of their own misdeeds; some appear malicious.Duration: 6+months--more or less daily for age 5 and under; weekly for older childrenDistress: px or othersDisability: edu/work, social, or personal impairmentDiff Dx: Substance use and physical disorders, ADHD, psychotic or mood disorders, disruptive mood dysregulation disorder, ordinary childhood growth and developmentSpecify severity:Mild.Sxs occur in only 1 location (home, school, with friends)Moderate. Some sxs in 2+ locationsSevere. Sxs in 3+ locationsODD sxs first show up around age 3 or 4; dx typical a few yrs later.It affects 3% of all children(boys predominate), 1-16%., when it occurs in girls are more verbal and less obvious. Over half who meet ODD will not do so several yrs later. Conduct Disorder(CD) will develop in about 1/3 of pxs, especially those whose ODD begins early and coexists with ADHD. 10% will eventually be dx with Antisocial personality disorder. The irritable mood sxs of ODD predict later anxiety and depression; defiance point toward CD. \*When mood disturbance is severe enough to meet criteria for disruptive mood dysregulation disorder, a dx of ODD is NOT given, even if all criteria for ODD are met.
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Essential Features for Conduct Disorder
In various ways, these people chronically disrespect rules and other people's rights.Most egregiously, they use aggression against their peers (and sometimes elders)--bullying, starting fights, using dangerous weapons, showing cruelty to people or animals, even sexual abuse. They may intentionally set fires or otherwise destroy property; breaking and entering, lying, and theft are well within their repertoires. Truancy, repeated runaways, and refusal against a parent's wishes to come home at night around their bag of tricks.Duration: 3/15 Sxs occurring within a year, & with at least 1+sx in the past 6 monthsDisability:Edu,work, social or personal impairmentDiff Dx: ADHD, ODD, mood disorders, ordinary childhood growth and development, Antisocial personality disorder, intermittent explosive disorderBased on age of onset, specify:Childhood-onset type. At least one problem with conduct begins before age 10.Adolescent-onset type. No problems with conduct before age 10.Unspecified onset. Insufficient information.Specify severity:Mild. Has sufficient, but not a lot of sxs, and harm to others is minimal.Moderate. Sxs and harm to others are intermediate.Severe. Many sxs, much harm to others.Specify if:With limited prosocial emotions. Such pxs lack emotional underpinnings.They have callous absence of empathy(that is without concern for the emotions or suffering of others). They tend to have limited affect and little remorse or guilt (other than regret if caught). They are indifferent to the quality of their own performance.\*Note: to receive the specifier With Limited Prosocial emotions, these sxs must be experienced within the past year.CD behavior can take 2 forms: one px who has trouble regulating powerful, angry, hostile emotions. These children come from dysfunctional families that are prone from physical abuse. Likely to be rejected from their peers, leading to aggression, playing truant, and associating with delinquents.Callous unemotional type-lacks empathy and guilt. These children tend to use others for their own gain. With low anxiety levels and tendency to become easily bored, they prefer activities that are novel, exciting, even dangerous. This subtype predicts an adolescence with more severe, persistent problems of conduct.
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Essential Features of Intermittent Explosive Disorder
The Px has frequent, repeated, spontaneous outburts of aggression (verbal or physical without damage) or less frequent physical eruptions with harm to people, property, or animals. These outbursts are unplanned, have no goal, and are excessive for the provocation.Duration: Aggression without harm ("benign aggression") 2 times a week for 3 months, or aggression with harm ("assault") 3 times in past yearDemographics: the px is 6+ years old or the developmental equivalentDiff dx: substance use and physical disorders, cognitive disorders, mood disorders, personality disorders, ordinary anger, adjustment disorder for children under age 18, disruptive mood dysregulation disorderAffects 7% of Americans lifetimes, higher in young people(younger than 35-40). Up to third of first degree relatives also have IED., a strong genetic component. A hx of childhood trauma is also higher in pxs with IED. If pxs with Bipolar I, it is important to make IED dx only when px is not in an episode of mania.In justification of dx-there are basically two patterns of outbursts (high-intensity/low-frequency and the reverse) and there may be pxs who may mix the patterns of behavior.
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Essential Features for Pyromania
These pxs set multiple fires, but without motivation for profit, revenge, an act of terrorism, or other gain. Rather, theirs is a general interest in fire and its appurtenances(fire trucks, the exciting aftermath). Such pxs feel tense or excited before starting the fire, and experience a sense of release or pleasure afterwards.Diff Dx: mood and psychotic disorders, CD, delirium or dementia, intellectual disability, ordinary criminal behavior80% male, begins in childhoodFire-setters have low self-esteem and reported problems getting along with peers. Look for coexisting CD, ASPD, substance misuse, and anxiety disordersPxs with schizophrenia, a manic episode, or other severe mental condition may sometimes set fires to communicate their desires(ex:to be released from jail, to be returned to a former place of residence). This behavior has been termed communicative arson. Another term is Consider for diff dx--Arson with a purpose: fires set as a matter of political protest or sabotage, or fires set for profit.
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Essential Features for Kleptomania
Pxs repeatedly act on the impulse to steal objects they don't really need. Before the actual theft, they experience mounting tension, which yields to a sense of release when the theft takes place.Diff dx: mood and psychotic disorders, personality and conduct disorders, ordinary criminal activity, revenge or angerWomen outnumber men 3:1, occurs in about 4-24% individuals arrested for shoplifting. 0.5%gen pop. Once it begins in childhood, it tends to be chronic.Look for substance misuse and depression as comorbid dx.
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Essential Features of Substance Use Disorder
These pxs use enough of their chosen substance to cause chronic or repeated problems in different areas of their lives:Personal and interpersonal life. They neglect family life (duties to spouse/partner, dependents) and even favorite leisure activities in favor of using their substance of choice; they fight (physically or verbally) with those they care about; and they continue to use despite the realization that it causes interpersonal problems.Employment. Effort formerly devoted to work (or other important activities) now goes to getting the substance, consuming it, and then recuperating from using its use. Result: These people are repeatedly absent or get fired.Control. They often use more of the substance or for longer than they intended; they (unsuccessfully) attempt to eliminate or reduce the usage. Through it all, they desperately crave more.Health and safety. Users engage in behavior that is physically dangerous (most often, operating a motor vehicle); legal issues can ensue. They continue to use despite knowing that it causes health problems such as cirrhosis or hepatitis C.Physiological sequels. Tolerance develops: The substance produces less effect, so the px must use more. And once they stop using, pxs suffer sxs of withdrawal characteristic of that substance.Tolerance isn't a factor with most hallucinogens, though users may develop tolerance to the stimulant effects of PCP. -Withdrawal isn't a factor of PCP, other hallucinogens, or inhalants. Don't count tolerance or withdrawal that's caused by taking medication as prescribed.Duration(the sxs you count must have occurred within the past 12 months)Diff Dx: physical disorders, primary disorders from nearly every other DSM-5 chapter, truly recreational useAdd Course Modifiers:Remission(Until px is clean or sober for 90 days, no designation of remission is possible)Early Remission: Begins after 3 months of being clean and sober for that substance(and without any of the substance use disorder sxs--with one allowed exception: craving and lasts until the person has been so for 1 year. (pxs are especially vulnerable to relapse during the first year of sobriety)In sustained remission. After the first year, sustained remission begins.In a Controlled Environment. Someone who is in early or sustained resmission and lives in an environment that restricts access to the substance may be given this modifier. Good control of contraband would characterize such an environment--a well run jail, therapeutic community, or locked hospital ward.In a controlled environment can apply to these classes of substance use: alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, or anxiolytics, stimulants,other(or unknown), tobacco.On Maintenance Therapy. A px who is taking a medication designed to reduce the effects of a substance may be described as on maintenance therapy.It is listed as a specifier for either opioids or tobacco, when there are currently no sxs of the substance use disorder. Why not alcohol, for which Antabuse? Well, then say so.Severity.Mild. Presence of 2-3 criteria substance use disorder criteriaModerate. Presence of 4-5 criteriaSevere. Presence of 6+ criteria.
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Essential Features of Substance Withdrawal
After using a substance heavily and at length, the px suddenly stops or makedly reduces intake. This yields a substance-specific syndrome that causes problems.Duration of the sx onset(generally hours to days)Diff dx: physical dxs, primary mental disordersCertain sxs are found in withdrawal from many substances:-Alteration in mood (anxiety, irritability, depression)-Abnormal motor activity(restlessness, immobility)-Sleep disturbance (insomnia or hypersomnia)-Other physical problems (fatigue, changes in appetite)EX: Hallucinogens can induce an addiction yet no withdrawal syndrome has been reported. The withdrawal has to do with the drug's half-life--the time it takes for the body to eliminate one-half of the substance. Usually withdrawal sxs begin within 12-14 hrs after the last dose is consumed and persist no longer than a few days. A powerful urge to resume use of the substance often accompanies the withdrawal sxs. EX: caffeine withdrawal, alcohol,heroin.Analysis of blood, breath, or urine can attest to the px's substance use more often evidence is obtained from hx. Denial may color self-report, so relatives or friend reports. As a rule of thumb, many clinicians mentally double the amount of a substance a px claims to have used.
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Essential Features of Alcohol Withdrawal
After heavy, long-lasting use of alcohol, the px suddenly stops or markedly reduces intake. Within hours to days, this yields sxs of increased nervous system and motor activity such as trembling, sweating, nausea, rapid heartbeat, high blood pressure, agitation, headache, insomnia, weakness, short-lived hallucinations/illusions, and/or convulsions.Duration: to onset (a few hrs to a day or more)Distress or disability: work, edu,social, or personal impairmentDiff dx: Physical illness, psychotic, mood, and anxiety disorders, withdrawal from sedatives and other substancesSpecify: With perceptual disturbances. The px has altered perceptions:auditory, tactile, or visual illusions or hallucinations with intact insight (that is, realization that the perceptual sxs are unreal, caused by the substance use.
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Essential Features of Substance Intoxication
Shortly after using a substance that can affect the central nervous system, the px develops characteristic physical sxs and clinically important behavioral or psychological changes that are maladaptive.Duration: to sxs onset (shortly after)Diff Dx: Physical disorders, intoxication from other substances, other mental disorders
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Essential Features of Alcohol Intoxication
Shortly after drinking alcohol, the px becomes disinhibited (argues, is aggressive; has rapid mood shifts or impairment of attention, judgment, or personal functioning). There is also evidence of neurological impairment (imbalance or wobbly gait, unclear speech, poor coordination, jerking eye movements called nystagmus, reduced level of consciousness).Diff Dx: physical disorders, intoxication from sedatives or other substances, other mental disorders
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Essential Features of Caffeine Intoxication
Shortly after consuming caffeine, the px develops sxs of increased nervous system and motor activity, such as fidgeting, increased energy, insomnia, rapid heartbeat, twitching muscles, intestinal upset, excess urination, red face, rambling speech.Duration to sx onset: recentDistress or disability: work, edu, social or personal impairmentDiff dx: physical disorders, intoxication from other substances, other mental disorderssxs appear anywhere from 250mg to 500mg of caffeine per day risks intoxicationA dx of caffeine intoxication is usually not made in people who are younger than 35.
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Essential Features of caffeine withdrawal
The px stops or markedly reduces teh extended, heavy intake of caffeine, yielding sxs suggesting flu (headache, nausea, muscle pain) and central nervous depression (fatigue, dysphoria, poor concentration)Duration to sx onset: 3+sxs within 1 dayDistress or disability:work, edu, social or personal impairmentDiff dx: physical disorders, intoxication from other substances, other mental disorders
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Essential Features of Cannabis Intoxication
Shortly after using cannabis, the px develops sxs of motor incoordination or altered cognition (anxiety or exhiliration, poor judgment, isolation from friends, a sense of slowed time) plus telltale red eyes, dry mouth, rapid heart rate, and hunger.Duration to sx onset(minutes to hrs, depending on route of administration)Diff dx: intoxication from hallucinogens and other substancesSpecify if: With perceptual disturbances. The px has altered perceptions: illusions of visions, hearing, or touch, or hallucinations with intact insight (the px recognizes that the sxs are unreal, caused by the substance use). Hallucinations without this insight suggest a dx of cannabis-induced psychotic disorder.
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Essential Features of Cannabis Withdrawal
After stopping major, long-lasting cannabis use, the px experiences sxs of dysphoria and central nervous system overactivity, along with troubled sleep, poor appetite, depression, anxiety, restlessness, and physical discomfort from shakiness, sweating, chills/fever, headache, or abdominal pain.Duration(heavy, daily use for months; onset within a few days of reduction)Distress or disability: work, edu, social, or personal impairmentDiff dx: physical disorders, other substance or mental disordersCoding allows only for one code for withdrawal (there must be a use disorder, and it can only be moderate or severe)
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Essential Features of Phencyclidine(PCP) Intoxication-Type of Hallucinogen
AKA Angel dust or PCP, has stimulant and depressant qualities. typical street dose 5mg, highly potent drug can produce psychotic sxs that cannot distinguish from schizophrenia. PCP was originally developed as an anesthetic agent;harmful side effects and no longer used in vet medicine. Cheap to produce, young men use it for euphoria it produces. Despite lack of withdrawal syndrome in humans, PCP has addictive potential as dangerous as cocaine and heroin. When swallowed, sxs begin within an hour; if smoked begin within few minutes. A high lasts from 4-6 hrs and repeated in runs lasting several days. PCP and kertamine are used by small number of individuals, especially males in their teens and 20s.Depending on dose variability of effects of PCP varies, besides euphoria experienced, PCP can produce lethargy, anxiety, depression, delirium, behavioral problems such as agitation, impulsivity, and assault.Catatonic sxs and suicide have been reported.Some experience violent,exaggerated, unpredictable responses to light or sound;physical sxs include high fever, muscle rigidity, muteness, and hypertension. Heavy doses can result in coma, and death from respiratory arrest.Shortly after using PCP, the px develops serious, sometimes lethal sxs of behavioral disinhibition--unpredictable impulsivity, aggression, poor judgement. With it, there are signs of neurological impairment and muscle dyscontrol:jerking eye movements called nystagmus, trouble walking or speaking, stiff muscles, numbness, coma, or seizures. Heartbeat or blood pressure can be high, and sometimes hearing seems abnormally acute.Duration to onset of sxs(within 1-2 hrs)Diff dx: physical disorders, intoxication from hallucinogens and other substances; other mental disorders, especially psychotic disorders
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Essential Features of Other Hallucinogen Intoxication
Shortly after using a non-PCP hallucinogen, the px develops sxs of dysphoria, misperception, or poor judgment, plus autonomic overactivity; dilated pupils and blurred vision, sweating, rapid or irregular heartbeat, trembling, reduced muscle coordination.Duration until onset of sxs (usually 1 hr or less)Diff dx: other substances, other mental disorders, other medical conditionsFirst sxs of other hallucinogen intoxication are usually somatic. Pxs may mention dizziness, tremor, weakness, or numbness, and tingling of extremeties. Perceptual changes (usually illusions) include apparent amplification of sounds and visual distortions (such as body image) as well as synesthesias (one type of sensory experience produces the sensation of another---saw red, white, and blue upon hearing a C-E-G chord played on a piano).Hallucinations, if they occur at all may be of vivid geometric forms or colors. Auditory hallucinations can occur. Intense euphoria, depersonalization(sense of detachment from oneself), derealization (a sense of unreality in one's perceptions), dream-like states, or the sense that time speeds up or slows down. Attention may be impaired, though most users retain insight. Some experience is pleasant and others " a bad trip." or are anxious. Some have fears of becoming psychotic. Usually negative reactions subside within 24hrs--the time it takes to excrete all of the drug.LSD is a potent agent;just a few micrograms(an amt soaked on a postage stamp) can produce significant sxs. It is absorbed from the gut and action usually begins within an hr. Effects tend to peak at 2-4 hrs and may last half a day. Can be lethal like PCP.
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Essential Features of Hallucinogen Persisting Perception Disorder
After stopping the use of a hallucinogen, the px again experiences at least one of the misperceptions that occurred during intoxication.Duration to sx onset(variable)Distress or disability: work, edu, social, or personal impairmentDiff dx: physical disorders, delirium, other mental disorders, hypnopompic imageryFlashbacks can include seeing faces, geometric forms, flashes of color, trails, afterimages, or halos; micropsia(things look small); and macropsia(things look huge). Diminished sex interest may be a feature. Px usually has insight into what is happening.Flashbacks may be triggered by stress, by entering a dark room, or by using marijuana or phenothiazines.Although brief flashbacks, lasting perhaps a few seconds, are common, over half of of hallucinogen user have them--only a small percentage report enough of these sxs to be distressing or to interfere with their activities. These experiences usually decrease with time; however they can occur weeks or months after use and persist for years.
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Essential Features of Inhalant Intoxication Disorder
Accidentally inhaled, a volatile substance is called a toxin; if it is used on purpose to produce intoxication, it is called an inhalant.Upon inhailing a chemical substance(e.g., glue, gasoline, solvents, thinners, various aerosols, correction fluid, and refrigerants), the px experiences poor judgment, aggression, or other behavior changes, plus various sxs of neuromuscular incoordination: trouble walking, lightheadedness, slow reflexes, trembling, weakness, blurred or double vision, drowsiness, jerking eye movements called nystagmus, unclear speech.Duration to onset(within moments)Diff dx: physical disorders, other mental disordersToulene is a widely abused solvent, associated with headache, high mood, giddiness, and cerebellar ataxia(irregular, uncoordinated movements often accompanied by poor balance, walking, with feet wide apart, and staggering). With smaller doses, there may be fatigue, headache, inhibited reflexes, and tingling sensations.Inhalants are usually absorbed by bagging or by huffing. When bagging, people spray, squeeze or pour the contents into a plastic bag and then inhale from the bag. They huff by placing the substance-soaked rags into their mouths and inhaling. Either method lasts for hrs. The use of multiple substances is common in these pxs, whose sxs may be due in part to the use of alcohol, cannabis, hallucinogens or tobacco. Chemical analysis for substances in px's blood or urine only way to ensure what substances px using.
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Essential Features of Opioid Intoxication
Shortly after using, the px experiences mood changes (first elation, later apathy), increased or reduced psychomotor activity, or poor judgment. Then come constricted "pinpoint" pupils(or dilated pupils, in overdose) along with evidence of depressed neurological functioning: lethargy, unclear speech, wandering attention, or poor memory.Differential Dx:physical illness, other mental disordersSpecify if: With perceptual disturbances. The px experiences hallucinations during which insight is retained. This unusual state must be discriminated from delirium. Overall, there is under half percent lifetime prevalence of severe opioid use in adult population, with rates falling off in older age cohorts. Males outnumber females by about 3:2. Even after detoxification, once opioid users return to familiar environments many begin to use again; usually this occurs within 3 months. Most users of heroin inject drug intravenously and half or more of these users test positive for HIV or hepatitis C.When injected with opioid drug, its effects are felt almost immediately. This "rush" compared to an orgasm, rapidly followed by euphoria, drowsiness, perception of warmth, dry mouth, and heaviness in the extremities. Some experience flushed face and itching nose. In contrast to cocaine intoxication, violence is rare during opioid intoxication. Extremely constricted pupils, however pupils can dilate in severe overdose. Urine and blood test necessary to differentiate causes of individual's sx's.Although opioid users often become tolerant to enormous quantities, overdose with opioids is always a medical emergency. It can clouding of consciousness (including coma), severe respiratory depression, shock, and ultimately death from anoxia. Opioid overdose is treated intravenously with naloxone, a potent opioid antagonist. Pxs often wear dark glasses to hide their pupils. There is physical stigmata from their scarring of the arms from injecting drugs.
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Essential Features of Opioid Withdrawal
Although some sxs of opioid withdrawal may appear after a very few doses, it takes a week or two of continuous use to produce the typical withdrawal syndrome. Opioid withdrawal strongly resembles a flu-like viral illness: nausea and vomiting, dysphoria, muscle aches and pains, watery eyes and runny nose, fever, and diarrhea. Another autonomic nervous system activation that occurs is piloerection: Small hairs stand up producing "goose flesh." Some pxs may suffer a protracted abstinence syndrome, characterized by anxiety and low self-esteem that can last as long as 5 to 6 months.After cutting back from several weeks of heavy opioid use, the px develops characteristic sxs of rebound excitation---dysphoria, nausea, diarrhea, muscle aches, tearing(running nose), yawning, sleeplessness, and autonomic sxs suxh as dilated pupils, hairs standing up and sweating.If withdrawal is induced by administering an opioid antagonist such as naloxone, signs and sxs will begin in minutes.Duration to sx onset(within several days)Distress or disability: work, social, or personal impairmentDiff dx: physical illness, other mental disorder
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Essential Features of Sedative-, Hypnotic-, or Anxiolytic-Intoxication
A sedative is anything that reduces excitement and induces quiet without producing drowsiness.A hypnotic helps the px get to sleep and stay there.An anxiolytic is one that reduces anxiety.\*When a drug is prescribed for medical purposes, Tolerance and Withdrawal are not to be used as sxs of a use disorder.Shortly after using a sedative, hypnotic, or anxiolytic drug, the px becomes disinhibited (argues;isaggressive;has rapid mood shifts or impairment of attention, judgment, or personal functioning). There is also evidence of neurological impairment (imbalance or wobbly gait, unclear speech, poor coordination, jerking eye movements called nystagmus, reduced level of consciousness).Diff dx: physical illness, alcohol intoxication, other mental disorders
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Essential Features of Sedative-, Hypnotic-, or Anxiolytic-Withdrawal
After heavy, long-lasting use of sedative, hypnotic, or anxiolytic drug, the px suddenly stops or markedly reduces intake. Within hours to days, this yields sxs of increased nervous system or motor activity such as trembling, sweating, nausea, rapid heartbeat, high blood pressure, agitation, headache, sleeplessness, weakness, short-lived hallucinations or illusions, convulsions.Duration to onset(a few hours to several days)Distress or disability: work, edu, social, or personal impairmentDiff dx: physical illness, psychotic mood, and anxiety disorders, withdrawal from alcohol; deliriumSpecify if: With perceptual disturbances. The px has altered perceptions:auditory, tactile, or visual illusions or hallucinations with intact insight (the px recognizes that the sxs are unreal, caused by the substance use).
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Essential Features of Stimulant Intoxication
Stimulants sometimes called psychostimulants affect mental and physical functioning, or both. These drugs typically improve--at least for a time--alertness, mood, and activity levels. Worldwide some stimulants are used by prescriptions to ameliorate the effects of both mental and physical disorders. Although caffeine is also a stimulant, it occupies its own niche among psychoactive drugs.DSM-5 mentions 2 main types of stimulants: amphetamines and cocaine.Sxs for intoxication and withdrawal are identical for these two classes of drugs, still their patterns of use are different.Shortly after using a stimulant drug, the px exhibits changes of mood/affect as well as impaired judgment or psychosocial functioning. In addition, there will be physical indicators of neurological excitation: lowered or raised blood pressure, heartrate, and motor activity; dilated pupils; sweating or chills; nausea; anorexia; and weakness, chest pain, respiratory depression, or irregular heartbeat. Very ill pxs may experience seizures, coma, or perplexity.Duration to onset of sxs(within minutes)Diff dx: physical illness, other mental disordersSpecify if:With perceptual disturbances. The px has altered perceptions:autitory,tactile, or visual hallucinations with intact insight (the px recognizes that the sxs are unreal, caused by the substance use). Hallucinations without this insight suggest a dx of stimulant-induced psychotic disorder.Amphetamine abusers value the euphoria, appetite suppression, and increase in energy the drug provides. Although many people begin amphetamine use by snorting, blood vessel constriction in the nose makes absorption unpredictable. So, smoking or injection are sought as it produces a rapid effect such that binge users take the drug repeatedly for half a day to 2-3days.Effects of the drug fall off rapidly as tolerance develops. This cycle of use and withdrawal that usually lasts about 10 days. Amphetamine users tend to look sleep-deprived and anorectic. Physical signs include circles under the eyes, poor hygeine, and dry, itchy skin that is prone to acne-like lesions. Those who inhale get nosebleeds, even perforated nasal septum. Toxic sxs include chest pain, palpitations, and shortness of breath. Tx now used for obesity, narcolepsy, some depressive disorders, and ADHD.Only 2% of emergency room drug-related visits due to amphetamines and their related substances. The substances related to amphetamine that are available by prescription include methamphetamine (Desoxyn), dextroamphetamine(Dexedrine), amphetamine combinations (Adderall), diethylopropion (Tenuate), and methylphenidate (Ritalin). With longer use person may begin to withdraw from people, hallucinations(such as bugs crawling on skin) or paranoid ideas can develop. Delirium may be accompanied by violence. Some adopt stereotyped behaviors such as reenactment of things they normally like to do.Any of these can resemble schizophrenia but clinician focus on longitudinal hx from informants and Lab studies to obtain origins of behavior.Cocaine has identical properties as amphetamines(alert, rush of euphoria, self-confidence, increased sexual desire), BUT the difference is the half-life in the body is much briefer. This may explain cocaine's greater addicting powers and appeal.With a short half-life, cocaine creates a powerful craving and users will use it more often than amphetamines. Toxic sxs are briefer than amphetamines. Severe intoxication includes convulsions, heartbeat irregularities, high fever, and death. Paranoid thinking increases as the binging goes on. Delusions (often of plots or attack on the user) are usually self-limited and brief (a matter of hours). Perceptual distortions occur; hallucinations are rare. Second most used illicit drug behind marijuana in U.S. and worldwide. About a quarter of drug-related visits to emergency rooms have been due to cocaine. Concentrated among younger adults (15-34)men more than women. Cocaine that has been heated with bicarbonate yields a white lump that is not destroyed by heating. It produces a popping sound when smoked; hence the name crack. Addiction to crack cocaine usually occurs after only a few weeks of use. Because almost no tolerance to cocaine develops, runs can continue for several days, though a day or less is more usual.Blood or urine specimen is necessary to know what a px is using for sure. After using drug and the positive feelings which last a few minutes, then the dysphoria and intense craving for more of the drug ensues. With continued use, the euphoric effects lessen and dysphoria(anxiety, depression, fatigue) takes over. Motivation is bent to a single goal:obtaining more cocaine.Behavioral changes associated with cocaine intoxication include aggression and agitation, often leading to fighting and hypervigilance. cocaine postpones fatigue and the resulting increase in energy breeds impaired judgment and increased willingness to take risks. Violence and crime are frequent products of the cocaine-intoxicated state. Cognitive sxs include delusions, feelings of omnipotence, ideas of reference(beliefs that external events have a special meaning unique to oneself) and haptic(tactile) hallucinations. Other sxs include irritability, increased sensory awareness, anorexia, insomnia, and spontaneous ejaculation. If intoxication is severe, there may be rambling speech, perplexity, anxiety, headache, and palpitations of the heart.
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Essential Features of Stimulant Withdrawal
After heavy, long-lasting use of a stimulant, the px suddenly stops or markedly reduces the intake. This yields sxs of dysphoria plus evidence of nervous system stimulation or exhaustion: intense dreams, reduced (sometimes increased) sleep or motor activity; feelings of hungerDuration to onset of sxs(hours to days)Distress or disability: work, edu, social, or personal impairmentDiff dx: physical illness, other mental disordersAmphetamine withdrawalAfter a few hours after the last use of amphetamines, there come the crash: agitation, anxiety, depression, and exhaustion. Intense craving that may wane in the face of depression, fatigue, and insomnia(which is accompanied by a paradoxical craving for sleep). Voracious appetite may develop. Fatigue and appetite worsen in the half day to 4 days following the crash; acute withdrawal lasts 7-10 days. Suicide attempts may result. user becomes a px. Cocaine WithdrawalAfter acute intoxication phase, blood cocaine levels drop rapidly. Unless more drug is immediately consumed, a rapid crash into depression occurs. The px may also experience irritability, suicidal ideas, fatigue, loss of interest, and a decreased ability to experience pleasure.Panic attacks are common; the need for cocaine is intense. Most of the sxs tend to increase for 2-4 days and then abate, but depression can linger for months. Suicide attempts are common;sometimes they succeed.About half of all those who have problems with cocaine use also have mood disorders, often bipolar or cyclothymic. This sets them apart from individuals with opioid-related disorders.
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Essential Features of Tobacco Withdrawal
The px suddenly stops or markedly reduces regular, prolonged tobacco use. Within a day, this yields multiple sxs of dysphoria (irritability, depression, anxiety), restlessness, trouble concentrating, insomnia, and hunger.Duration to onset of sxs(within 24 hrs)Distress of disability: work, edu, social, or personal impairmentDiff dx: physical illness, other mental disordersThere is a positive correlation between addiction to tobacco and alcoholism, schizophrenia, and other mental disorders. Tobacco produces nausea, vomiting, and anxiety in novice smoker. Although it has been reported to reduce anxiety, although it may be curing the tobacco withdrawal sxs. Usually people start socially and get hooked. Most people who are withdrawing of tobacco often complain most bitterly not of specific sxs but of yearning for a cigarette. The craving can overwhelm ability to focus. The result is a moody, anxious person who sleeps poorly and eats too much. Onset of withdrawal sxs occurs within a day of last use and is often detectable within a few hours. Withdrawal will occur in about half of those who stop using.
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Essential Features of Gambling Disorder
Gambling so takes over the lives of these px's that they will borrow, lie, and otherwise jeopardize important relationships or opportunities. As they try to recoup their losses, they may risk more money; repeated (and futile) efforts at control yield irritability and restlessness. Some gamble as a way of coping with stress. Some borrow or steal from others to relieve their increasingly desperate financial straits.Duration(a year or more)Distress or disability: work, edu, social, or personal impairmentDiff dx: Substance use disorders, manic episode, professional gambling, social bettingSpecify if course is:EpisodicPersistentSpecify if: In {early}{sustained} remission. No criteria for gambling disorder are met for {3-12 months}{over 1 year}Specify severity:Mild. Meets 4-5 criteriaModerate. Meets 6-7 criteria.Severe. Meets 8-9 criteria.Pathological Gambling has striking similarities between the use of substances in that, in both the activation of reward centers (ventral striatum) of the brain (dopamine) is implicated. Males outnumber females 2:1, women develop gambling problems later than men and seek tx earlier. Broad range of gambling activities: store scratching tickets to bingo to casual sports, slot machines, poker, dice, dogs, and ponies.
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Essential Features of Delirium
A delirium is a rapidly developing, fluctuating state of reduced awareness in which the following are true:-The px ha trouble with awareness(operationally defined as orientation) and shifting or focusing of attention, and-The px has at least one defect of memory, orientation, perception, visuospatial skills, or language, and-The sxs are not better explained by coma or another cognitive disorderA major or mild neurocognitive disorder (NCD) differs from delirium in several ways:-The time course is relatively slow.Delirium develops across hours or days, an NCD across weeks and months.-Although pxs with NCDs can have impaired ability to focus or shift attention, it isn't prominent.-The cause of an NCD can usually be found within the central nervous system; the cause of delirium is often elsewhere in the body.-Some pxs recover from an NCD, but this isn't the usual course.Although the brain can be involved directly (as with a brain tumor or seizure disorder) most deliriums are caused by disease processes that begin outside the central nervous system. These include endocrine disorders, infections, drug toxicity or withdrawal, vitamin deficiency, fever, liver and kidney disease, poisons, and the effects of surgical operations.Basic sxs of delirium:-In just hours to several hours, the px develops...-reduction in awareness and attention, accompanied by...-some sort of additional cognitive deficit such as problems with orientation, memory, language, perception, or visuospatial capability.-The intensity of these sxs tends to fluctuate during the course of a day.Inattention first sx notice.During interview px has difficulty focusing on topic at hand, may experience drowsiness or somnolence. Thought process slow down and appear vague, detect trouble with reasoning and solving problems. May have to ask questions several times before px responds. On the other hand, inattention may appear as hyperalert distractibility, with rapid shifting from one focus to another.Any of the several areas can constitute the additional cognitive deficit; two or more may occur at the same time.1. Language-speech is rambling, disjointed, pressured, or incoherent, or speech leaps from one topic to another.Some pxs have trouble writing or naming things. Speech in merely slurred without incoherent thoughts, suggests intoxication, not delirium.2. Memory. Delirious pxs nearly always have trouble remembering things. Recent events always affected first. Older memories (especially those from childhood) are usually the last to go.3. Executive functioning. The person has difficulty in planning, organizing, sequencing, or abstracting information. In practice, the person has trouble making decisions, taking steps that break a habit pattern, correcting errors, or searching for the source of a problem(troubleshooting). Obviously, novel or complicated situations will be fraught for these people.4.Orientation. Many pxs will be disoriented, so severely that you cannot examine them adequately. Disorientation is most likely to be for time(date, day, month, year), next comes disorientation for place, last px fail to recognize relatives or friends(disorientation of person). Only the most severely ill pxs are unsure of their own identities.5. Perception. Pxs with even mild or early delirium don't perceive their surroundings as clear as usual:Boundaries are fuzzy, colors are abnormally bright, images distorted. Some pxs misidentify what they see(illusions), whereas others experience false perceptions (hallucinations-visual). If they later experience false beliefs or ideas (delusions) grafted onto their halucinations, these delusions are usually incomplete, changing, or poorly organized. Confronted by visual misperceptions, pxs may not be able to tell whether they are dreaming or awake. Those who accept their hallucinations as reality may feel quite anxious or fearful.Other areas often revealing delirium include:Sleep-wake cycle: Insomnia, day-night reversal, vivid dreams, nightmaresPsychomotor activity and behavior. Physical movements may sometimes be slowed, especially if delirium is due to metabolic problems. These pxs appear retarded and sluggish. Others may experience increased motor activity(agitated behavior, picking at clothes). A flapping tremor of hands is common. So are vocalizations, which are muttering or moans and some may weep or call out. Those who feel threatened may strike out or attempt to escape.Mood. Depression and fear are common reactions. Mood is unstable, perceived by others as lability of affect. Dysphoria may present sometimes but then there is danger of dx as MDD, when sx of delirium. Some pxs will only react with perplexity; still others will exhibit bland calm acceptance or perhaps even intense anger or euphoria.Delirium usually begins suddenly and its intensity often fluctuates. Most pxs will be more lucid in the morning and worse at night--a transient phenomenon called sundowning. When suspect delirium, interview px several hours apart because the sxs of delirium fluctuate with time of day where evening times may give clearer evidence of illness. If multiple appts not practical, nursing staff or charting notes may provide needed info. Though sxs may persist for days or weeks, most deliriums last a week or less and then resolve once the underlying condition has been relieved. Some, will evolve into dementia. After delirium resolves, most pxs recall the experiences incompletely; they may have amnesia for certain or all aspects or may seem like a dream if recall anything. Delirium is common in medical wards where it is mistaken for other mental disorders, including psychosis, depression, mania, "hysteria" or personality disorder.Delirium has the highest incidence of mental disorders. Half of hospitalized elderly pxs become delirious. It is more common in children and elderly than young and middle-aged adults.Neurologists and internists refer to delirium as "acute confusional state," Other terms include, "toxic psychosis" "acute brain syndrome" and "metabolic encephalopathy."Over a short-time, the px develops problems with attention that wanders and with orientation9especially to the environment); additional cognitive changes(memory, use of language, disorientation in other spheres, perception, visuomotor capability). Severity fluctuates during the day. The cause can be pinned on a physical condition, substance use, toxicity, or some combination.Duration of onset(hours to days; generally brief, though it can endure)Diff Dx: major neurocognitive disorder, coma, psychotic disordersSpecify if:Hyperactive. Agitation or otherwise increased level of activityHypoactive. Reduced level of activityMixed level of activity.Normal or fluctuating activity levels.Specify duration:Acute.Lasts hours to a few days.Persistent. Lasts weeks or longer.
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Essential Domains important for the study of DSM-5 Major and Mild Neurocognitive Disorders (NCDs)
1. Complex Attention means the ability to focus on tasks in such a way that their completion isn't derailed by distractions. It is more than the simple attention span you evaluate when you ask a px to repeat a string of digits or spell world backwards. It also involves processing speed, holding information in mind, and being able to attend (more or less) to more than one thing at once, like writing a grocery list while listening to the radio. In mild NCD, a px may be able to perform tasks when a lot is going on, but it will take extra effort.EX: px trouble using computer.if a call interrupts her, it may take a couple of minutes trying to determine where she left off. She used to read the newspaper and write email online; now she must limit herself so as to not become confused. Ex:Another px had increasing difficulty dressing himself. If talking to someone, he gets distracted and is likely to leave one shoe untied.2. Learning and Memory. Memory exists in many variations--mneumonic PEWS for:Procedural memory.That's the sort of memory we need for skills such as typing and playing the flute and riding a bicycle.It allows us to learn a sequence of behaviors and repeat them without having to expend conscious effort.Episodic memory.Memory for events the individual has experienced as personal hx-the night Mom died,where you went on your last vacation,your dessert choice at supper yesterday. Episodic memory always takes our personal point of view; it is often visual.Working memory. Short-term storing of data that we are actively processing. We test it by asking the px to do mental arithmetic or spell words backwards. It is often regarded as synonymous with immediate memory and regarded as an executive function.Semantic memory. General knowledge--in short, facts and figures. This is where most of what we learn ends up, because we no longer associate it with anything concrete in our lives, such as where we were when the learning took place.As memory deteriorates, the time it takes to process information increases.3.Perceptual-Motor Ability is one's ability to assimilate visual and other sensory information and use it. The use is usually motor, though also included would be facial recognition, which lacks a motor component. Note that the sensory abilities themselves are just fine: The person can see things well like average person but has difficulty navigating immediate environment,especially when perceptual cues are reduced(as twilight or nighttime).Handwork and crafts take extra effort;copying a design onto a sheet of paper could be a real problem. Problems in this domain exists on a continuum from nil to mild to major.Ex:px relied on sign on door to know where senior living apt door was located. Later she walked past sign and had to have someone direct her to room.4.Executive Functioning is the set of mechanisms people use to organize simple ideas and bits of behavior into more complex ones on the way to a goal, such as dressing or finding their way around town. When executive functioning is affected, pxs have trouble interpreting new information and adapting to new situations. Planning and decision making become difficult. As mental flexibility is lost, behavior becomes driven by habit rather than by reason and feedback error correction.EX: more and more trouble in the kitchen. px used to do a different menu each day of the week, now does mac and cheese and forgets the salt. Twice last month he forgot the pan on the cooktop and started a small fire.5.Language domain: includes both receptive (understanding) and expressive language. The latter includes naming (the ability to state the name of an object such as a fountain pen), fluency, grammar, and syntax(structure) of language. Some pxs may use circumlocutions to get around words they can't remember. Increasingly they may depend on cliches; they may become vague, circumstantial, or (in the end) completely mute.EX:px developed a naming aphasia. she said the word "thingy" for an increasing variety of objects she encountered. another px into dementia mixed up words such as table and chair.6.Social cognition refers to the processes that help us recognize the emotions of other people and respond to them appropriately. It includes decision making, empathy, moral judgment, knowledge of social norms, emotional processing, and theory of mind--the ability to imagine that other people have beliefs and desires, and to recognize that others may have ideas different from our own. A person with defects in social cognition may have difficulty recognizing the emotion portrayed in a scowling (or smiling) face.These people who have damage to the amygdala, may be overly friendly toward others. Some, however, don't adhere to accepted standards of propriety or conventional societal interaction.-Note:Confusion is a term often used to describe slowed thinking, loss of memory, perplexity, or disorientation in pxs with major or mild neurocognitive disorders. Neurologists and internists as well as gen public us it. DSM-5 even sneaks it in once in a while but it is an inexact term that is inexact.
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Essential Features of Major and Mild Neurocognitive Disorders
Someone (the px, a relative, the clinician) suspects that there has been a {marked}{modest} decline in cognitive functioning. On formal testing, the px scores below accepted norms by {2+}{1-2} standard deviations. Alternatively, a clinical evaluation reaches the same conclusion. The sxs {materially}{do not materially} imapir the patient's ability to function independently. That is, the patient, {cannot}{can} negotiate activities of daily life (paying bills, managing medications) by putting forth increased effort or using compensatory strategies such as keeping lists.One standard deviation below norms would be at the 16th percentile; 2 would be at the 3rd percentile.Duration(symptoms tend to chronicity)Diff dx:delirium, normal aging, major depressive disorder[pseudodementia], psychosisSpecify if:With behavioral disturbance (specify type). The px has clinically important behaviors such as apathy, agitation, or responding to hallucinations or mood problems.Without behavioral disturbance. The px has no such difficulties.For major NCD, specify current level of severity:Mild. The px requires help with activities of daily living, such as doing housework or managing money.Moderate. The px needs help even with such basics as dressing and eating.Severe. The px is fully dependent on others.Whatever the underlying etiology the pxs with NCD share a number of features that serve as criteria for dx. Then the difference between the Major and Mild forms of NCD boils down to severity of the sxs.DeclineNCD implies loss.decline from a previous level in one or more areas of functioning. Pxs who have always functioned at a low level (individuals with low intellectual disability) do not necessarily have an NCD.However, like anyone else, can develop an NCD. Even a child who suffers a decline due to lasting effects of a traumatic brain injury may be said to have suffered NCD.Ex: loss of memory is paramount in Alzheimer's and other disorders like vascular disease may not have a prominent cogntive domain deficit/decline. Other pxs may develop problems with language, executive functioning, perceptual-motor functions, or social cognition. But there is always a decline. Overall prevalence ranges NCD depend on definition 2% on age 65, 5-10% at age 75, 15-30% at age 80 and above. Recent research suggests increased exercise, decreased smoking, improved diet may help reduce the onset of NCD in older people.Not Exclusively a DeliriumAn NCD cannot be diagnosed if sxs occur only when the px is delirious. However, these conditions often and do coexist as when a px with NCD due to Alzheimer's is given medication that produces a substance intoxication delirium.Confirmed by TestingNCD criteria require that testing confirm the px's decline. Formal tests of px's cognitive domain(s) are preferred but that is not going to happen so bedside estimates of ability will have to serve as substitute.DSM-5 now emphasizes a combination of two requirements--testing and concern on the part of those who know the person.ImpairmentHere's the big difference between Major (dementia) and Mild NCD: The loss of cognitive ability must be severe enough to have a definite impact on the patient's work or social life. The impact doesn't have to be severe;some px's will be able to function satisfactorily with some help-paying bills or shopping. People with mild NCD can continue to function independently if they put forth more effort. The difference between Major and Mild NCD is one of degree. Note for some pxs mild NCD will not progress to Major NCD. The trouble is we might not be able in advance to tell one group from the other.The onset is gradual(though the course depends on the cause). The first indication is the loss of interest in work or leisure activities. family or friends may note a change in long-standing personality traits. When executive functioning is affected, judgment and impulse control suffer. Loss of social graces ensues(px makes crude jokes and neglects personal hygiene and appearance). Stripped of the ability to analyze, to understand, to remember, and to apply old knowledge to new situations, the px may be left to rely upon skeleton old habit.Pxs with NCDs become increasingly vulnerable to psychosocial stresses.Some become apathetic, irritable, some ignore the desires or interests of their group. Another might try to compensate for failing memory by making lists. The misperceptions(hallucinations or illusions) so common in delirium are often absent, especially early in the process. As major NCD worsens, paranoid ideas and delusions of infidelity can lead to abusive, even assaultive behavior.Some pxs are placid early in the illness as apathy leads to gradually reduced activity. Those who retain insight may become depressed and anxious. Later, a person who becomes frustrated or frightened may experience outbursts of anger. Restlessness and pacing can lead to wandering from home; pxs may remain lost for hrs or days. A person in the final stage of major NCD may lose all useful speech and self-care and end up confined to bed, unaware of attendants or family.Most cases of NCD are found in older pxs, it can be dx after age 3 or 4, which is when person's cognitive functioning becomes reliably measurable. The course depends on the underlying cause.Most often it is of chronic cause. Some NCD can become static or remit. Remission is likely in NCD due to hypothyroidism,subdural hematoma, or normal-pressure hydrocephalus. When one of these causes is dx early and is successfully tx, full recovery can occur. The suspicion of NCD demands medical and neurological evaluation to confirm causation and whenever possible to intervene with tx.
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Essential Features of NeuroCognitive Disorder Due to Alzheimer's Disease
The px has a {major}{mild} neurocognitive disorder that begins slowly and progress gradually.Duration: chronicDiff dx: delirium, age-related cognitive decline, intellectual disability; depressive, anxiety, or psychotic disorders; substance intoxication; other causes of NCD,especially vascular, frontotemporal and Lewy body diseasesThere are two ways to arrive at a dx of probable major NCD due to Alzheimer's demetia, and one way each to a dx of possible major, probable mild, or possible NCD due to Alzheimer's disease.Major NCD due to Alzheimer's Probable:Meets criteria for major NCD, Insidious onset, gradual progression of disability, Two or more domains affected; Positive genetic testing or family hx for Alzheimer's disease; steady decline, no extended plateaus, no evidence of mixed causes, decline in memory and learningMild NCD Probable:Meets criteria for major NCD, Insidious onset, gradual progression of disability, One or more domain affected; Positive genetic testing or family hx for Alzheimer's disease
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Essential Features of Neurocognitive Disorder with Lewy Bodies
The px has a {major}{mild} neurocognitive disorderBeginning slowly and progressing gradually, the disease has these core features: wide fluctuation in attentiveness; elaborate, clear hallucinations; and sxs of parkinsonism that begin a year or more after the cognitive sxs.Some pxs have features that suggest Disorder with Lewy Bodies(DLB): REM sleep behavior disorder, marked sensitivity to neuroleptic drugs.Duration:tends to chronicityDiff dx:delirium, substance related disorders, depressive or psychotic disorders; other causes of NCD--especially Alzheimer's, vascular, and frontotemporal diseasesProbable NCD with Lewy bodies: One core feature plus one or more core or suggestive feature yields a dx of {mild}{major}NCD with probable Lewy bodiesPossible NCD with Lewy bodies: One core or suggestive feature is enough for a dx of {mild}{major}NCD with possible Lewy bodiesCore features: -Fluctuating alertness and attention-Repeated,vivid,detailed hallucinations-Parkinsonism that begins only after the cognitive declineSuggestive features:-REM sleep behavior disorder-Exquisite sensitivity to neurolepticsNote: You can't code with behavioral disturbance, but if you note it's there, you should mention it in writing anywayDLB second largest cause of demetia--it accounts for 15% of cases, as against 60-75% for Alzheimer's.Over a million DLB pxs in US alone. Lewy bodies are spherical bits of proteins found in cytoplasm of brain cells located especially in the brainstem nuclei, substantia nigra, and locus ceruleus. Pxs with DLB also have amyloid plaques that are typical of Alzheimer's disease as well.Core feature: fluctuating attention. and alertness over minutes, hours, or days that waxes and wanes.; hallucinations-visual occur early and tend to persist;content of animals or intruders, with or without insight and may be accompanied by delusions.Later onset of Parkinson's-type sxs. Typical motor features of Parkinson's disease-immobile face, hand tremor, shuffling gait--constitute third core sx-but they cannot predate dementia.If they do, it cannot be DLB at all, but rather Parkinson's disease with dementia. The rule of thumb: DLB sxs must begin at least a year before motor sxs appear.Pxs with DLB are also prone to dizziness, falls, and unexplained spells. Depression is common, as is autonomic dysfunction (orthostatic hypotension, incontinence of urine). REM sleep behavior disorder is noted sometimes. Early detection and tx is important because px may be exquisitely sensitive to neuroleptics. Relatively low doses may cause muscle rigidity, fever, and other sxs of neuroleptic malignant syndrome.DLB typically begins around age 75; men are affected more often than women. After dx typical px lives 10 yrs.
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Essential Features of Neurocognitive Disorder due to Traumatic Brain Injury
Immediately following head trauma that causes rapid movement of the brain inside the skull, the px becomes unconscious or may develop amnesia, disorientation and perplexity, or neurological signs such as seizures, blind spots in the visual field, loss of smell, hemiparesis, or an injury demonstrated by imaging (CT,MRI). Subsequently, the px has sxs of a {mild}{major} neurocognitive disorder.Duration(starts immediately, lasts a week or more)Diff dx: delirium, age-related cognitive decline, depression, psychotic disorders, substance intoxication, anxiety disorders, other causes of NCD--especially Alzheimer's diseaseMotor vehicle accidents (including pedestrians) are leading cause; second leading is falls from elderly and sports in young people (women athletes more than men).The sxs of TBI are caused by a disruption of brain structure or physiology that results from external force exerted upon the head. Immediate loss of consciousness is usual. After awakening, pxs may have trouble focusing and maintaining attention. Delirium is common. Even after it clears, deficits in attention is commonplace. Many pxs complain of trouble with memory (anterograde or retrograde). Language functions affect a third of pxs with severe TBI. These include fluent receptive aphasias, though nonfluent(expressive) aphsias are also well represented. Executive functioning is commonly affected. px will also complain of problems with sleep, headaches, and irritability.Though it can take months, most pxs eventually recover. Common sequels include depressive disorders(most frequent) anxiety disorders, and substance misuse. Personality change is sometimes noted. A preinjury mental disorder greatly increases the risk for a postinjury disorder. TBI if repeated may increase likelihood of Alzheimer's by fourfold. Some writers note that the differentiation of NCD due to TBI from posttraumatic stress disorder can be challenging.
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Essential Features of Frontotemporal Neurocognitive Disorder
The px has a {mild}{major} neurocognitive disorder. The sxs begin slowly and progress gradually. The px's sxs will be mainly of one of these two types:Behvaiorally variant. The px behaves in socially inappropriate ways that may include poor manners, loss of decorum, or rash impulsivity; apathy or inertia; reduced capacity for compassion; compulsive behavior; and hyperorality(binge eating, pica, drinking, smoking) and alterations of diet. Visuomotor skills will be relatively unimpaired, but there tends to be clear evidence of impaired frontal/executive functioning, such as reduced mental flexibility, decreased generation tasks, planning deficits, and reversal learning errors.Language variant. In the face of relatively unimpaired memory and visuomotor function, there is gradual loss of the ability to produce speech, to find the right word, to attach names to objects, and to use grammar and understand the meaning of words.Duration: chronicDiff dx: mood and psychotic disorders; other causes of NCD--especially Alzheimer's, Lewy bodies,Defensiveness of dxSpecify if:Probable frontotemporal NCD. A pathogenic mutation is known to exist(via genetic tests or family hx), or imaging shows heavy frontotemporal involvement.Possible frontotemporal NCD. Neither characteristic of a probable dx is present.Once called Pick's disease, frontotemporal NCD--FTD-used to be considered rare. Now it accounts for 5% of cases of dementia and one in six younger pxs, it's mean age onset is 50s. Often familial; half of cases are transmitted as an autosomal dominant trait.FTD Affects frontal and temporal lobes.
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Essential Features of Vascular Neurocognitive Disorder
The px has a {mild}{major} neurocognitive disorder. The sxs begin after a vascular event and often progress stepwise. There is often prominent decline in complex attention and frontal/executive functioning.Duration:tends to chronicityDiff dx: delirium, other causes of NCD--especially Alzheimer's and frontotemporal, mood and psychotic disordersSpecify if:Vascular NCD probably due to vascular disease. The dx is reinforced by neuroimaging, by proximity(following a cerebrovascular accident), or by both clinical and genetic evidence.Vascular NCD possibility due to vascular disease. None of the three sorts of evidence cited above obtains.Specify if: {with}{Without} behavioral disturbance.Approximately 10% of dementias have a vascular origin. AKA multi-infarct dementia because often a series of strokes, though some pxs are affected by a single event and other may have small vessel disease that doesn't produce infarcts. Many pxs with Vascular NCD worsen through a series of small steps as the strokes occur. Progression can appear slow and gradual---likely to happen in px who has diabetes or hypertension. Besides failing memory, pxs experience loss of executive functioning, which shows up as inability to deal with novel tasks. Apathy, slowed thinking, and deteriorating hygeine. Relatively mild stressors may precipitate pathological laughing or crying. These pxs are less likely than pxs with Alzheimer's to have aphasia, apraxia, and agnosia, though any aspect of mental functioning can be affected.The sxs of vascular NCD depend on the exact location of brain lesion(s) but several characteristics are typical, such as subcortical ischemic vascular disease. they include early impairment of executive function and attention, slowed motor performance, and slowed performance, and slowed processing of information. Episodic memory is less affected than in Alzheimer's, but mood sxs(depression, lability) and apathy are especially prominent.
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Essential Features of Neurocognitive Disorder Due to Other Medical Conditions
Parkinson's disease. The stooped posture, slow movements, rigidity, back-and-forth("pill-rolling") tremor, and rapid, shuffling gait characteristic of Parkinson's disease are well known and obvious.Huntington's disease. Age of onset for Huntington's disease averages around 40 years, the first sxs may be repeatedly minor changes in personality and executive functioning, followed by deteriorating memory and judgment. A generalized restlessness may precede the characteristic involuntary choreiform movements and slowing of voluntary movements. Prevalence is about 6 per 100,000 in North America and Europe. The cause is an autosomal dominant gene on chromosome 4.Prion disease. Prion disease is at once miniscule and huge. It accounts for a tiny fraction of all dementias--perhaps 1 case per million population per year--yet its "mad cow disease" form is so dramatic (and unusual) that it makes headlines whenever it occurs. The more common type, Creutzfeldt-Jacob disease, is caused by an infectious protein that contains no nucleic acids (that is, no DNA or RNA). These diseases attack the brain, creating the holes in microscopic sections that account for the collective name spongiform encephalopathies. Sxs include memory loss, hallucinations, personality change, and motor problems. Though the age range is wide, it usually occurs in the elderly; a few cases are familial. Usually fatal within a year, prion disease is essentially untreatable.HIV infection. Improvements in antiviral therapy have reduced the various threats posed by HIV infections; yet up to half of those infected will have sxs of cognitive dysfunction, and up to a third meet criteria for mild or major NCD. It is principally a subcortical type of infection with a variable presentation. Although HIV infection is not one of the more common causes of dementia, it has rapidly become one of the most important, ocurring in young people and laying waste otherwise vigourous lives. Other causes. The sxs and course of illness depend heavily on the underlying medical cause. So do tx and prognosis. They might include normal-pressure hydrocephalus, hypothyroidism, brain tumor, vitamin B12 deficiency, and many others.
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Essential Features of Substance/Medication-Induced Neurocognitive Disorder
The use of some substance appears to have caused a px to have a {major}{mild} neurocognitive disorder.Diff dx: numerous other causes of NCDWhen writing down the dx, use the exact substance in the titleEX: alcohol-induced major neurocognitive disorderSpecify if:Persistent. Sxs of the NCD continue long past the time it should take to recover with prolonged abstinence.NCDs can result from prolonged use of alcohol, sedatives, and inhalants, though vast majority alcohol is chief culprit. Pxs will have difficulty with constructional tasks(e.g., drawing), behavioral problems, and memory defects. Described as having delusional jealousy or hallucinations. Onset is typically gradual, nothing may be noted amiss until the px has dried out several days or weeks. One form of the disorder is Korsakoff's psychosis or DSM-IV called it substance-induced persisting amnesic disorder. DSM-5 calls it alcohol-induced major NCD, amnestic-confabulatory type.
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Essential Features of General Personality Disorder
ClusterA: Paranoid, Schizoid, SchizotypalWithdrawn, cold, suspiscious, or irrationalCluster B: Antisocial, Borderline, Histrionic, NarcissisticTheatrical, emotional, and attention-seeking;their moods are labile and often shallow.They often have intense interpersonal conflicts.Cluster C: Avoidant, Dependent, Obsessive-CompulsiveTend to be anxious and tense, often overcontrolledDiagnosing Personality Disorders:1.Verify the duration of the sxs. Make sure px sxs present at least since early adulthood (before age 15 for antisocial PD). Interviewing informants (family, friends, coworkers) will give valid material.2.Verify the sxs affect several areas of pxs life.work, school, personal life and social life affected? Pxs may not see themselves that their behavior causing problems("It's the world that's out of step.")3. Check that the px qualifies for the particular dx in question. Checking all characteristics and checking all 10 sets of dx criteria. sometimes you need to make a judgment call. 4. If px is under 18, make sure sxs have been present for at least past 12 months.(Make sure not due to other mental or physical disorder).5.Rule out other mental pathology that may be more acute and have greater potential for doing harm.6.Review generic features and things missed. Note that must have two or more types of lasting problems with behavior, thoughts, or emotions from a list of 4: cognitive, affective, interpersonal, and impulsive.(ensures px's problems truly affect more than one life area).7. Search for other PDs. Evaluate entire hx. May only note person has traits. ex: schizoid and paranoid traits.8. Record personality and nonpersonality mental diagnoses. ex: lacerations in arm, nodding of head
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Essential features of Paranoid Personality Disorder
In many situations, these pxs demonstrate that they distrust the loyalty or trustworthiness of others. Because they suspect that other people want to deceive, hurt, or exploit them, they hesitate to share personal information. Unjustified suspicions about the faithfulness of spouse or partner, or even the {mis}perception of hidden content in everyday events or speech, can lead to the bearing of grudges or to rapid response with anger or attacks in kind.Duration:Begins in teens or early 20s and enduresDiffuse contextsDiff dx: physical and substance use disorders, mood, anxiety, and psychotic disorders, PTSD, schizotypal and schizoid PDs.If PPD precedes the onset of schizophrenia, add the specifier (premorbid)1% of general population; typically in men.
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Essential Features of Schizoid Personality Disorder
In many situations, these pxs remain isolated and have a narrow emotional range. Preferring solitude in their activities, they neither want or enjoy close relationships, including those with family. They may have no close friends, with the possible exception of relatives. Indeed, they enjoy few activities, even showing little interest in sex with other people. Emotionally cold or detached, they seem indifferent to both criticism and praise.Duration: Begins in teens and early 20s and endures, Diffuse contextsDiff dx:physical and substance use disorders, mood and psychotic disorders, autism spectrum disorders, schizotypal and paranoid PDsIf schizoid disorder precedes the onset of schizophrenia, add the specifier (premorbid)
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Essential Features of Schizotypal Personality Disorder
In many situations, these pxs tend to be isolated and exhibit a narrow emotional range with other people. They will have paranoid or suspicious ideas, even ideas of reference(which, however, are not held to a delusional extent). Their dress or mannerisms may give them an odd appearance, with affect that is inappropriate or constricted; speech can be vague, impoverished, or overly abstract. They may report strange perceptions or physical sensations, and their peculiar behavior may be affected by magical thinking or other odd beliefs (superstitions, a belief in telepathy). With severe social anxiety (which doesn't improve with acquaintance), they tend to have no intimate friends.Duration: begins in teens or early 20s and enduresDiffuse contextsDiff dx:physical and substance use disorders, mood and psychotic disorders, autism spectrum disorder and other neurodevelopmental disorders, paranoid and schizoid PDsIf Schizotypal PD precedes the onset of schizophrenia, add the specifier (premorbid)Pxs with schizotypal PD may eventually develop schizophrenia. Many pxs have depression when first present to clinical attention. Their eccentric ideas and style of thinking place them at risk for becoming involved in cults. They get along poorly with others and under stress may become briefly psychotic. Despite odd behavior, many marry and work. This disorder occurs about as often as schizoid PD.
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Essential Features of Antisocial Personality Disorder
Cluster BThese pxs have a hx dating to before age 15 of destroying property, serious rule violation, or aggression against people or animals (that is, they fulfill criteria for conduct disorder). Since then, in many situations, they lie, con, or give an alias while engaging in behvaiors that merit arrest (whether or not they are actually detained). They tend to fight or assault others, and generally fail to plan their activities, relying instead on the inspiration of the impulse. For none of this behavior do they show remorse, other than feeling sorry if caught. They will refuse to pay their debts or maintain steady employment. They may irresponsibly place themselves or other people in danger.Duration and demographics: dx cannot be made prior to age 18; behavior patterns are enduringDiffuse contextsDiff dx: physical and substance use disorders, bipolar disorders, schizophrenia, other PDs, ordinary criminalityDSM-5 criteria for ASPD specify that, beginning before age 15, the px must have a hx that would support a dx of conduct disorder; as an adult, this behavior must have continued and been extended, with at least 4 ASPD sxs.As many as 3% of men, and 1% women have this disorder. found in 3/4 of penitentiary prisoners. Childhood ADHD is a precursor and childhood conduct disorder is a requirement. Male relatives have ASPD and substance-related disorders; female relatives have somatic sx disorder and substance-related disorder.Although tx seems to make little difference to pxs with ASPD, there is evidence the disorder decreases with age, and become "only" substance users. Death by suicide or homicide is the lot of others.Only about half of children who are delinquent, have problems with school truancy, and are marked incorrigible develop the full adult ASPD syndrome.Therefore, it is best to not diagnose ASPD before age 18.
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Essential Features of Borderline Personality Disorder
These pxs exist in a perceptual crisis of mood or behavior. They often feel empty or bored. Disturbed identity(insecure self-image) can lead them to attach themselves strongly to others and then reject these same people with equal vigor. On the other hand, they may frantically try to avert desertion (it can be actual or fantasied). Pronounced impulsiveness can lead them to harm or mutilate themselves or to engage in other potentially harmful behaviors, such as sexual indiscretions, spending sprees, eating binges, or reckless driving. Although stress can cause brief episodes of dissociation or paranoia, these quickly resolve. Intense, rapid mood swings may yield to anger that is inappropriate and uncontrolled.Duration: begins in teens and early 20s and enduresDiffuse contextsDiff dx: physical and substance use disorders, mood and psychotic disorders, other PDs.
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Essential Features of Histrionic Personality Disorder
These pxs not only crave the limelight, but are unhappy when they are not the focus of attention. They actively attempt to draw attention to themselves with their physical appearance and mannerisms. Their manner of speaking may be overly dramatic, but what they say tends to be vague, lacking specificity. They can be gushing and fleeing. Too open to suggestion, too readily influenced, these people may interpret relationships as being intimate when they are not--even to the extent of behaving in ways that are improperly suggestive or seductive.Duration: begins in teens or early 20s and enduresDiffuse contextsDiff dx: physical and substance disorders, somatic sx disorder, other PDs.
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Essential Features of Narcissistic Personality Disorder
These people possess grandiosity, together with a craving for admiration. To get it, they typically exaggerate their own abilities and accomplishments. They tend to be preoccupied with fantasies of beauty, brilliance, perfect love, power, or limitless success, and believe that they are so unusual that they should associate with people or institutions of rarefied status. Often arrogant or haughty, they may believe that others envy them (though the reverse may actually be true). Lack of empathy engages their feelings of privilege in justifying the exploitation of others to achieve their own goals.Duration: begins in teens or early 20s and enduresDiffuse contextsDiff dx: physical and substance use disorders, other PDs
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Essential Features of Avoidant Personality Disorder
Cluster CThese pxs are socially inhibited, are overly sensitive to criticism, and feel inadequate. Feeling themselves inferior, unappealing, or clumsy, they are reluctant to form new relationships. Such people so fear ridicule or shame that they will only become involved with others if they can know in advance they will be accepted. Otherwise, their worry about being rejected or criticized (or embarrassed) on the job or in social situations will lead them to avoid new pursuits.Duration: begins in teens or early 20s and enduresDiffuse contextsDiff dx:physical and substance use disorders, social anxiety disorder, paranoid and schizoid PDs
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Essential Features of Dependent Personality Disorder
The need for supportive relationships draws these people into clinging, submissive behavior and fears of separation. Fear of disapproval makes it hard to disagree with others; to gain support, they will even take extraordinary steps, such as assuming unpleasant tasks. Low self-confidence prevents them from starting or carrying out projects independently; indeed, they want others to take responsibility for their own major life areas. If they do make even everyday decisions, they require lots of advice and reassurance. Exaggerated, unrealistic fears of abandonment and the notion that they cannot care for themselves will cause these people to feel helpless or uncomfortable when alone; they may desperately seek a replacement for a lost close personal relationship.Duration: begins in teens or early 20s and enduresDiffuse contextsDiff dx: physical and substance use disorders, mood and anxiety disorders, other PDs
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Essential Features of Obsessive-Compulsive Personality Disorder
These people are intensely focused on control, orderliness, and perfection. They can become so absorbed with details, organization, and rules of an activity that they lose sight of its purpose. They tend to be rigid and stubborn, perhaps so perfectionistic that it interferes with the completion of tasks. They can be overly conscientious, inflexible, or scrupulous about ethics, morals, and values. Some are workaholics, other won't work unless others agree to do things the px's way. Some may save worthless items;others are stingy with themselves and with other people.Duration:begins in teens or early 20s and enduresDiffuse contextsDiff dx: physical and substance use disorders, OCD, hoarding disorder, other PDs
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Essential Features of Personality Change Due to Another Medical Condition
A physical Illness or injury appears to have a px to suffer a lasting personality change.From their expected developmental pattern, children will experience a personality change that lasts at least 1 year.Duration: enduringDistress or disability: work, edu, social, or personalDiff dx: delirium, other physical or mental disordersDepending on the main feature, specify type:Aggressive typeApathetic typeDisinhibited typeLabile typeParanoid typeOther typeCombined typeUnspecified typeUse the actual name of the general medical condition when code this disorder and also code separately the medical condition.EX: Epilepsy or Huntington's disease can cause personality changes, or systematic diseases that can affect the brain like systematic lupus erythematosis. Mood may become unstable, perhaps with outbursts of rage or suspiciousness; othe pxs may become apathetic and passive. Damage to frontal lobes of brain can cause changes in mood. Pxs with temporal lobe epilepsy may become overly religious, verbose, and lacking a sense of humor, some may turn aggressive. Paranoid ideas are also common. Belligerence can accompany outbursts of temper to extent that social judgment can be impaired.If the problem stems from a chemical problem, they may resolve. When severe, they can ultimately lead to dementia as is sometimes the case in pxs with multiple sclerosis.
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Essential Features of Exhibitionistic Disorder
The person is aroused by genital self-exposure to an unwary stranger and has repeatedly acted on the urge(or feels distress/disability(or has free time) at the idea).Duration: 6+ monthsDistress or disability: work, edu, social or personalDiff dx: physical or substance use disorders, psychotic and bipolar disordersSpecify type:Sexually aroused by exposing genitals to prepubertal childrenSexually aroused by exposing genitals to physically mature individualsSexually aroused by exposing genitals to prepubertal children and to physically mature individualsSpecify if:In full remission(no sxs for 5+yrs)In a controlled environmentUsually exhibitionists begin before age 18, but may persist until age 30 or later. Often urge comes in waves. May yield daily for a week or two,then remain inactive for weeks or months. Usually behavior most often occurs if px under stress or has free time. The use of alcohol is seldom a factor. Many have spouses or partners and have normal sex lives, interest in sex may be greater than average. Perhaps 15% will have an offense involving contact such as coercion, pedophilia, or rape. A full assessment of paraphilic interests is indicated.
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Essential Features of Sexual Masochism Disorder
The px has sexual urges to being injured, bound, or humiliated,Duration:6+monthsDistress or disability: work, edu, social or personalDiff dx: physical or substance use disorders, psychotic and bipolar disorders, transvestic fetishism, sexual sadism disorder, hypersexualitySpecify if:With asphyxiophilia.If the individual engages in the practice of achieving sexual arousal related to restriction of breathing.Specify if:In full remission(no sxs for 5+yrs)In a controlled environment
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Essential Features of Fetishistic Disorder
The person is aroused by inanimate objects (such as shoes or underwear) or body parts other than genitals (such as feet) and feels distress/disability at the idea.Duration:6+monthsDistress or disability: work, edu, social or personalDiff dx: transvestic disorderSpecify if:Body partsNonliving objectsOther(perhaps combination of the first two types)Specify if:In RemissionIn a controlled environmentFetishism usually begins in adolescence, though many pxs report similar interests in childhood. Some women show some degree of fetishistic behavior, nearly all those with disorder are men. It tends to be a chronic condition. Without a fetish, a person may be unable to get an erection. Many fetishists have also been involved in rape, exhibitionism, frotteurism, pedophilia, or voyeurism.
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Essential Features of Frotteuristic Disorder
Aroused by rubbing against or feeling someone who hasn't consented, the px has repeatedly acted on the urge (or feels distress/disability at the idea).Duration: 6+ monthsDistress or disability: work, edu, social or personalDiff dx: physical or substance use disorders, psychotic and bipolar disordersSpecify if:In full remission(no sxs for 5+yrs)In a controlled environmentThe perpetrator will usually select a victim(usually a woman) who is accessible and has tight clothing. The frotteur rubs his genitals against her thighs or buttocks or he may fondle her breasts or genitalia. The process is efficient;on subways, ejaculation usually occurs within the transit time between stops. The victim typically does not make an immediate outcry because she hopes its a mistake what is happening. Note that it is the act of touching or rubbing, not the coercion involved, that is exciting to the frotteur. However, over half have a hx of other paraphilias, exhibitionism, and voyeurism. A frotteur often fantasizes about an ongoing intimate relationship with the victim. This condition usually begins in adolescence and is sometimes started off by observing others engaged in frottage. Most acts occur when the frotteur is between ages 15 and 25; frequency gradually declines thereafter. No one knows how common condition is.
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Essential Features of Pedophilic Disorder
The px is sexually aroused by prepubescent children and has acted on the urge (or feels distress/interpersonal impairment at the idea).Duration: 6+monthsDemographics: the px must be at least 16 years old and at least 5 years older than the victimDiff dx: physical and substance use disorder, psychotic and bipolar disorders, intellectual disability, criminal abuse of children for profitSpecify if:In a controlled environmentSpecify:Exclusive type(aroused solely by children)NonexclusiveSpecify if:Sexually attracted to malesSexually attracted to femalesSexually attracted to bothSpecify if:Limited to IncestUp to 20% of American children have been interfered with sexually, most perpetrators are relatives, friends, or neighbors; most are men, women account for 12%-some involve allowing children to be abused rather than committing act.Some pedophiles only view child pornography or actual children; others want to touch or undress children. Most acts involve oral sex or touching genitals.Incest, some don't require penetration and some use force. Though some pedophiles do not start until midlife, this behavior begins in later teenage years.Many pedophiles limit themselves to children--called type of pedophilia is exclusive (to certain age and sex). Overall 15-25% of those convicted reoffend within a few years of their release from prison. Alcohol use (50% use it) and trouble forming intimate adult relationships increase the chances of recidivism. Men who prefer boys over girls are twice as likely to reoffend.Type of Limited to Incest can be used when pedophiles limit their attention to daughters, stepdaughters, or other victims related to them. Another issue is raised with a 20 year old having sex with a 14 or 15 year old may not be diagnosed as pedophile because of DSM-5 5 year age difference between perpetrator and victim with a prepubertal child.
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Essential Features of Sexual Sadism Disorder
The px, who is aroused by someone else's sufferring, has acted upon the urge with someone who hasn't consented(alternatively, the px feels distress/disability at the idea).Duration: 6+ monthsDistress or disability:work, edu, social or personal impairmentDiff dx: physical and substance use disorders, personality disorders, nonsadistic rapeSpecify if:In full remission(no sxs for 5+ years)In a controlled environmentSadists are the perpetrators, inflicting pain or humiliation sexually stimulates them. The suffering of others arouses them sexually and they fantasize about dominance and restraint. Some women admit to engaging in this activity.Physical methods employed include bondage, blindfolding, spanking, cutting, and humiliation(such as defecation, urination, or forcing the submissive partner to imitate an animal). With time, Sadists may need to increase the severity of the torture to produce the same degree of sexual satisfaction. Most people limit themselves to only a few partners, most who are willing. Fewer than 10% of sadists commit rape but those who do can be even more brutal than other rapists using more force and inflicting greater pain than is necessary to fulfill their needs.
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Essential Features of Transvestic Disorder
Arousal by cross-dressing (thoughts or behaviors) has repeatedly caused the px to feel distressed or impaired.Duration: 6+ monthsDistress or disability: work, edu, social or personal impairmentDiff dx: physical and substance use disorders, gender dysphoria, fetishistic disorderSpecify if:With fetishism (sexual arousal by clothing or fabrics)With autogynephelia(sexual arousal by self-visualization as female)Specify if:In Full Remission (no sxs for 5+ years)In a controlled environmentWomen who are sexually aroused by visualizing themselves as male can be dx as- autoandrophilia.
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Essential Features of Voyeuristic Disorder
Aroused by watching an unwary person who is undressing or having sex, the px has repeatedly acted on these urges or has experienced distress or impairment from them.Duration: 6+ monthsDemographics: 18+Distress or disability:work, edu, social or personal impairmentDiff dx: conduct disorder/antisocial personality disorder, substance use disorders, normal sexual interestsSpecify if:In Full Remission (no sxs for 5+ years)In a controlled environmentVoyeur's gratification derives from viewing ordinary people who do not realize they are being watched and would probably not permit it if they did.Usually starts at age 15, once develops it usually is chronic. Usually will masturbate while watching strangers. Afterwards will fantasize about having sex with the victim though activity with the victim is rarely sought. They take precautions to avoid detection, like exhibitionists.
