DISORDERS’ DIAGNOSTIC CRITERIA Flashcards
(105 cards)
1
Q
Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached.
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- Lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
- Characterized by children’s unrealistic and persistent worry that something bad will happen to their parents or other important people in their lives or that something will happen to the children themselves that will separate them from their parents.
A
SEPARATION ANXIETY DISORDER [SAD]
2
Q
Consistent failure to speak in specific social situations in which there is a expectation for speaking [e.g., at school] despite speaking in other situations.
- At least 1 month [not limited to the first month of school]
- The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
- Rare childhood disorder characterized by a lack of speech in one or more setting in which speaking is socially expected.
- Usually before age 5 years
A
SELECTIVE MUTISM [SM]
3
Q
Marked fear or anxiety about a specific object or situation [e.g., flying, heights, animals, receiving an injection, seeing blood]
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.
- The phobic object or situation almost always provokes immediate fear or anxiety.
- The phobic object or situation is actively avoided or endured with intense fear or anxiety.
- Specify if: animals, natural environment, blood injection injury
- Acquired through direct experience, experiencing in false alarm, and observing others.
A
SPECIFIC PHOBIA [SP]
4
Q
Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions [e.g., having a conversation, meeting unfamiliar people], being observed [e.g., eating or drinking], and performing in front of others [e.g., giving a speech].
Note: In children, the anxiety must occur in peer settings and not just during interaction with adults.
Note: In children, the fear and anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
The social situations are avoided or endured with intense fear or anxiety.
A
SOCIAL ANXIETY DISORDER [SAD] / also known as SOCIAL PHOBIA
5
Q
Individuals fear a range of situations.
A
GENERALIZED SOCIAL ANXIETY DISORDER
6
Q
Individuals have more limited fear.
A
SPECIFIC SOCIAL ANXIETY DISORDER
7
Q
Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four [or more] of the following symptoms occur:
Note: The abrupt surge can occur from a calm state or an anxious state.
- Palpitations, pounding heart, or accelerated heart rate
- Sweating
- Trembling or shaking
- Sensations of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling dizzy, unsteady, light-headed, or faint
- Chills or heat sensations
- Very rare in childhood.
10. Parenthesias [numbness or tingling sensations]
11. Derealization [feelings of unreality] or depersonalization [being detached from one self]
12. Fear of losing control or “going crazy”
13. Fear of dying
Note: Culture-specific symptoms [e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying] may be seen. Such symptoms should not count as one of the four required symptoms.
A
PANIC DISORDER [PD]
8
Q
Marked fear or anxiety about two [or more] of the following five situations:
- Using public transportation [e.g., automobiles, buses, trains, ships, planes]
- Being in open spaces [e.g., parking lots, marketplaces, bridges]
- Being in enclosed places [e.g., shops, theaters, cinemas]
- Standing in line or being in a crowd
- Being outside of the home alone
The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms [e.g., fear of falling in the elderly, fear of incontinence].
- Develops after a person has unexpected panic attacks.
- Before 35 years old, with 21 years the mean age
- Persistent and chronic
A
AGORAPHOBIA [AGORA]
9
Q
Excessive anxiety and worry [apprehensive expectation], occurring more days than not for at least 6 months, about a number of events or activities [such as work or school performance].
- The individual finds it difficult to control the worry.
- The anxiety and worry are associated with three [or more] of the following symptoms [with at least some symptoms having been present for more days than not for the past 66 months]:
Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance [difficulty falling or staying asleep, or restless, unsatisfying sleep].
A
GENERALIZED ANXIETY DISORDER [GAD]
10
Q
Characterized by excessive anxiety and worry that is not limited to any one object, situation, or activity. The intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated event.
- at least 6 months or more
- Females are twice as likely as males to experience this.
A
GENERALIZED ANXIETY DISORDER [GAD]
11
Q
Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges or images that are experienced, at some time during disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action [i.e., by performing a compulsion].
Compulsions are defined by (1) and (2):
1. Repetitive behaviors [e.g., hand washing, ordering, checking] or mental acts [e.g., praying, counting, repeating words silently] that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
A
OBSESSIVE-COMPULSIVE DISORDER [OCD]
12
Q
Intrusive and mostly nonsensical thoughts, images, or urges that the individual tries to resist or eliminate.
A
OBSESSIONS
13
Q
Thoughts or actions used to suppress the obsessions and provide relief.
A
COMPULSIONS
14
Q
4 MAJOR TYPES OF OBSESSIONS:
A
- SYMMETRY
- FORBIDDEN THOUGHTS OR ACTIONS [AGGRESSIVE/SEXUAL/RELIGIOUS]
- CLEANING/CONTAMINATION
- HOARDING
15
Q
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
- “Imagined Ugliness”
- Formerly known as “Dysmorphophobia”
A
BODY DYSMORPHIC DISORDER [BDD]
16
Q
The individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.
A
MUSCLE DYSMORPHIA
17
Q
Preoccupation with some imagined defect in
appearance by someone who actually look
reasonably normal. They may also be
preoccupied with other body areas, such as
skin or hair. A majority (but not all) diet,
exercise, and/or lift weights excessively,
sometimes causing bodily damage.
A
BODY DYSMORPHIA
18
Q
Persistent difficulty discarding or parting with possessions, regardless of their actual value.
- This difficulty is due to perceived need to save the items and to distress associated with discarding them.
- The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties [e.g., family members, cleaners, authorities].
- May first emerge around ages 15-19 years old
- Often chronic
A
HOARDING DISORDER [HD]
19
Q
Recurrent pulling out one’s hair, resulting in hair loss.
- Repeated attempts to decrease or stop hair pulling.
- The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- May be seen in infants, resolved during early development.
A
TRICHOTILLOMANIA [HAIR-PULLING DISORDER]
20
Q
Recurrent skin picking resulting in skin lesions.
- Refers to skin-picking disorder, where a person repeatedly picks at their own skin, often causing harm or damage.
- Most often has onset during adolescence, usually begins as with dermatological condition.
A
EXCORIATION [SKIN-PICKING] DISORDER
21
Q
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
- The child rarely or minimally seeks comfort when distressed.
- The child rarely or minimally responds to comfort when distressed.
- Show lack of preferred attachment despite having attained a developmental age of at least 9 months.
- Experienced history of severe social neglect.
- Diagnosis should be made with caution in children older than 5 years.
A
REACTIVE ATTACHMENT DISORDER [RAD]
22
Q
A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults.
- Overly familiar verbal or physical behavior [that is not consistent with culturally sanctioned and age-appropriate social boundaries].
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
- Willingness to go off with an unfamiliar adult with minimal or no hesitation.
A
DISINHIBITED SOCIAL ENGAGEMENT DISORDER [DSED]
23
Q
Exposure to actual or threatened death, serious injury, or sexual violence in one [or more] or the following ways:
- Directly experiencing the traumatic event(s)
- Witnessing, in person, the events as it occurred to others.
- Learning that the traumatic events occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the events must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic events [e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse].
- Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic events.
- Exposure to a traumatic event during which an individual experiences or witnesses death or threatened death, actual or threatened serious injury, or actual or threatened sexual violation.
A
POSTTRAUMATIC STRESS DISORDER [PTSD]
24
Q
Exposure to actual or threatened death, serious injury, or sexual violence in one [or more] or the following ways:
- Directly experiencing the traumatic event(s)
- Witnessing, in person, the events as it occurred to others.
- Learning that the traumatic events occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the events must have been violent or accidental.
- Experiencing repeated or extreme exposure to aversive details of the traumatic events [e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse].
- Cannot be diagnosed until 3 days after a traumatic event.
- If the symptoms persists for more than 1 month and meet the criteria for PTSD, then diagnosis will be changed to PTSD.
A
ACUTE STRESS DISORDER [ASD]
25
The development of emotional or behavioral symptoms in response to an identifiable stressors occurring within 3 months of the onset of the stressors.
These symptoms or behaviors are clinically significant, as evidenced by one or both of the following:
1. Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation.
2. Significant impairment in social, occupational, or other important areas functioning.
ADJUSTMENT DISORDERS [AD]
26
The death, at least 12 months ago, of a person who was close the bereaved individual [for children and adolescents, at least 6 months ago].
- Focused on feelings of loss and separation from a loved one rather than reflecting generalized low mood.
- Involves distress from deceased person.
PROLONGED GRIEF DISORDER [PGD]
27
Individuals are pathologically concerned with the functioning of their bodies; have an excessive or maladaptive response to physical symptoms or to associated health concerns.
- SOMATIC SYMPTOM DISORDER
- ILLNESS ANXIETY DISORDER
- PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION
- FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER [CONVERSION DISORDER]
- FACTITIOUS DISORDER
These disorders are sometimes grouped under the shorthand label of “medically unexplained physical symptoms”
SOMATIC SYMPTOM AND RELATED DISORDERS
28
Individuals experience intense and extreme alterations, or detachments, in consciousness or identity (dissociation or dissociative experiences) that they lose their identity entirely and assume a new one, or they lose their memory or sense of reality and are unable to function.
- DEPERSONALIZATION-DEREALIZATION DISORDER
- DISSOCIATIVE AMNESIA
- DISSOCIATIVE IDENTITY DISORDER
DISSOCIATIVE DISORDERS
29
Somatic symptom and dissociative disorders are strongly linked historically and used to be categorized under one general heading, _______ _______.
HYSTERICAL NEUROSIS
30
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health
concerns as manifested by at least one of the following:
(1) Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
(2) Persistently high level of anxiety about health or symptoms
(3) Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
- Sometimes only one severe symptom, most commonly pain is present.
- Symptoms may be specific (e.g., localized pain) or relatively nonspecific (e.g., fatigue)
- The symptoms sometimes represent
normal bodily sensations or discomfort that does not generally signify serious disease.
- formerly known as Briquet’s syndrome
SOMATIC SYMPTOM DISORDER
31
A. Preoccupation with having or acquiring a serious illness.
B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical
condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
- Preoccupation with physical symptoms. Physical symptoms are either not experienced at
the present time or are very mild, but severe anxiety is focused on the possibility of having or developing a serious disease; the concern is primarily with the idea of being sick instead of the physical symptom itself; individual is preoccupied with bodily symptoms, misinterpreting them as indicative of illness or disease.
- While the concern may be derived from a nonpathological physical sign or sensation, the individual’s distress emanates not primarily from the physical complaint itself but rather from his or her anxiety about the meaning, significance, or cause of the complaint (i.e., the suspected medical diagnosis)
- formerly known as “hypochondriasis”
ILLNESS ANXIETY DISORDER
32
Generally have to do with physical malfunctioning, such as paralysis, blindness, or difficulty speaking (aphonia), without any physical or organic pathology to account for the malfunction.
- There may be one or more neurological symptoms of various types.
- Motor symptoms include weakness or paralysis; abnormal movements, such as tremor, jerks, or dystonic movements; and gait movement.
- Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing.
CONVERSION DISORDER [FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER]
33
Requires the presence of medical conditions as well as psychological factors that adversely affect its course or interfere its treatment.
Example: Anxiety severe enough to clearly worsen an asthmatic condition.
PSYCHOLOGICAL FACTORS AFFECTING MEDICAL CONDITION
34
A. The presence of persistent or recurrent experiences of depersonalization, derealization, or both:
1. Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one’s thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing).
2. Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).
B. During the depersonalization or derealization experiences, reality testing remains intact.
- Severe and frightening feeling of unreality that they dominate an individual’s life and prevent normal functioning.
DEPERSONALIZATION-DEREALIZATION DISORDER
35
- Perception alters and temporarily loses the sense of one’s own reality, as if you were in a dream and you were watching yourself.
- A feeling of unreality or detachment from, or unfamiliarity with, the individual’s whole self or from aspects of the self.
- The individual may feel detached from his or her:
- entire being (e.g., “I am no one,” “I have no self”)
- feelings (e.g., hypoemotionality: “I know I have feelings, but I don’t feel
them”)
- thoughts (e.g., “My thoughts don’t feel like my own,” “head filled with
cotton”)
- whole body or body parts, or sensations (e.g., touch, proprioception,
hunger, thirst, libido).
DEPERSONALIZATION
36
- Sense of the reality of the external world is lost
- A feeling of unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings.
- Feel as if he or she were in a fog, dream, or bubble, or as if there were a veil or a glass wall between the individual and the world around.
DEREALIZATION
37
Characterized by an inability to recall autobiographical information that is inconsistent with normal forgetting.
- memory deficits are primarily retrograde and often associated with traumatic experiences.
An inability to recall important autobiographical information, usually of a traumatic or stressful nature, that is inconsistent with ordinary forgetting.
DISSOCIATIVE AMNESIA
38
- characterized by apparently purposeful travel or bewildered wandering
- associated with amnesia for identity or other important autobiographical information. subtype of dissociative amnesia
- amnesia for travel
- commonly associated with generalized dissociative amnesia.
DISSOCIATIVE FUGUE
39
An an individual enters a trancelike state and suddenly, imbued with a mysterious source of energy, runs or flees for a long time.
RUNNING DISORDERS
40
Individuals in this trancelike state often brutally assault and sometimes kill people or animals.
- Most common in males
AMOK
41
Types of Dissociative Amnesia
1. Localized
2. Selective
3. Systematized
4. Generalized
42
A failure to recall events during a circumscribed period of time.
LOCALIZED
43
The individual can recall some, but not all, of the events during a circumscribed period of time.
SELECTIVE
44
The individual fails to recall a specific category of important information.
SYSTEMATIZED
45
Involves a complete loss of memory for most or all of the individual’s life history.
GENERALIZED
46
A. Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession. The disruption in identity involves marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition,and/or sensory-motor functioning. These signs and symptoms may be observed by others or reported by the individual.
B. Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.
- characterized by a) the presence of two or more distinct personality states or an experience of possession and b) recurrent episodes of dissociative amnesia.
- may adopt as many as 100 new identities, all simultaneously coexisting, although the average number is closer to 15.
DISSOCIATIVE IDENTITY DISORDER
47
The person who becomes the patient and asks for treatment.
HOST
48
Transition from one personality to another.
SWITCH
49
An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time, or be depressed with a few symptoms of mania. This episode is characterized as having ______ _______.
MIXED FEATURES
50
The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by related changes that significantly affect the individual’s capacity to function (e.g., somatic and cognitive changes in major depressive disorder and persistent depressive disorder).
DEPRESSIVE DISORDERS
51
The most easily recognized mood disorder is _______ _______ _______, defined by the presence of depression and the absence of manic, or hypomanic episodes, before or during the disorder. An occurrence of just one isolated depressive episode in a lifetime is now known to be relatively rare.
MAJOR DEPRESSIVE DISORDER
52
A. Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day
(observable by others, not merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
MAJOR DEPRESSIVE DISORDER
53
_______ _______ _______ is defined by the presence of at least one major depressive episode occurring in the absence of a history of manic or hypomanic episodes. The essential feature of a major depressive episode is a period lasting at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in all or nearly all activities for most of the day nearly every day (Criterion A).
MAJOR DEPRESSIVE DISORDER
54
This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder.
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
- The essential feature of ______ ______ _______ is a depressed mood that occurs for most of the day, for more days than not, for at least 2 years, or at least 1 year for children and adolescents (Criterion A).
PERSISTENT DEPRESSIVE DISORDER
55
A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
B. One (or more) of the following symptoms must be present:
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to
rejection).
2. Marked irritability or anger or increased interpersonal
conflicts.
3. Marked depressed mood, feelings of hopelessness, or
self-deprecating thoughts.
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.
- The essential features of _______ _______ _______ are the expression of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase of the cycle and remit around the onset of menses or shortly thereafter.
PREMENSTRUAL DYSPHORIC DISORDER
56
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
- The core feature of ______ ______ ______ ______ is chronic severe, persistent irritability. This severe irritability has two prominent clinical manifestations, the first of which is frequent temper outbursts. The second manifestation of severe irritability consists of chronic, persistently irritable or angry mood that is present between the severe temper outbursts.
DISRUPTIVE MOOD DYSREGULATION DISORDER
57
For a diagnosis of ______ __ ______, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes.
- ______ __ ________ is characterized by a clinical course of recurring mood episodes (manic, depressive, and hypomanic), but the occurrence of at least one manic episode is necessary for the diagnosis of ______ __ ________.
- The essential feature of a manic episode is a distinct period during which there is an abnormally, persistently elevated, expansive, or irritable mood and persistently increased activity or energy that is present for most of the day, nearly every day, for a period of at least 1 week (or any duration if hospitalization is necessary), accompanied by at least three additional symptoms from Criterion B. If the mood is irritable rather than elevated or expansive, at least four Criterion B symptoms must be present.
BIPOLAR I DISORDER
58
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).
MANIC EPISODE
59
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.
HYPOMANIC EPISODE
60
Five (or more) of the following symptoms have been present during the same 2- week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
MAJOR DEPRESSIVE EPISODE
61
For a diagnosis of _______ __ _______, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode:
- ______ __ _______ is characterized by a clinical course of recurring mood episodes consisting of one or more major depressive episodes (Criteria A–C under “Major Depressive Episode”) and at least one hypomanic episode (Criteria A–F under “Hypomanic Episode”).
BIPOLAR II DISORDER
62
A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode.
B. During the above 2-year period (1 year in children and adolescents), Criterion A symptoms have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
C. Criteria for a major depressive, manic, or hypomanic episode have never been met.
- The essential feature of ______ ________ is a chronic, fluctuating mood disturbance involving numerous periods of hypomanic symptoms and periods of depressive symptoms (Criterion A). The hypomanic symptoms are of insufficient number, severity, pervasiveness, and/or duration to meet full criteria for a hypomanic episode, and the depressive symptoms are of insufficient number, severity, pervasiveness, and/or duration to meet full criteria for a major depressive episode.
CYCLOTHYMIC DISORDER
63
Characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning.
FEEDING AND EATING DISORDERS
64
Major Types of Eating Disorder
- PICA
- RUMINATION DISORDER
- AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER
- ANOREXIA NERVOSA
- BULIMIA NERVOSA
- BINGE-EATING DISORDER
65
A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially normative practice.
- Typical substances ingested tend to vary with age and availability and might include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal or coal, ash, clay, starch.
PICA
66
A. Repeated regurgitation of food over a period of at least 1 month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
B. The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition [e.g., gastroesophageal reflux, pyloric stenosis].
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
RUMINATION DISORDER
67
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) associated with one (or more) of the following:
1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
2. Significant nutritional deficiency.
3. Dependence on enteral feeding or oral nutritional supplements.
4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.
AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER
68
The main diagnostic feature of ________ _________ ______ _______ is avoidance or restriction of food intake that is associated with one or more of the following consequences: significant weight loss, significant nutritional deficiency (or related health impact), dependence on enteral feeding or oral nutritional supplements, or marked interference with psychosocial functioning (Criterion A).
AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER
69
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
- Persistent energy intake restriction; intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain; and a disturbance in self-perceived weight or shape. The individual maintains a body weight that is below a minimally normal level for age, sex, developmental trajectory, and physical health (Criterion A). Individuals’ body weights frequently meet this criterion following a significant weight loss, but among children and adolescents, there may alternatively be failure to make expected weight gain or to maintain a normal developmental trajectory (i.e., while growing in height) instead of weight loss.
ANOREXIA NERVOSA
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A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
BULIMIA NERVOSA
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Recurrent episodes of binge eating (Criterion A), recurrent inappropriate compensatory behaviors to prevent weight gain (Criterion B), and self-evaluation that is unduly influenced by body shape and weight (Criterion D). To qualify for the diagnosis, the binge eating and inappropriate compensatory behaviors must occur, on average, at least once per week for 3 months (Criterion C).
BULIMIA NERVOSA
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A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
1. Eating much more rapidly than normal.
2. Eating until feeling uncomfortably full.
3. Eating large amounts of food when not feeling physically hungry.
4. Eating alone because of feeling embarrassed by how much one is eating.
5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.
BINGE-EATING DISORDER
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All involve the inappropriate elimination of urine or feces and are usually first diagnosed in childhood or adolescence. This group of disorders includes
enuresis, the repeated voiding of urine into inappropriate places, and encopresis, the repeated passage of feces into inappropriate places.
ELIMINATION DISORDERS
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A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional.
B. The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
C. Chronological age is at least 5 years (or equivalent developmental level).
D. The behavior is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder).
- The essential feature of ________ is repeated voiding of urine during the day or at night into bed or clothes (Criterion A). Most often the voiding is involuntary, but occasionally it may be intentional.
ENURESIS
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A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether involuntary or intentional.
B. At least one such event occurs each month for at least 3 months.
C. Chronological age is at least 4 years (or equivalent developmental level).
D. The behavior is not attributable to the physiological effects of a substance (e.g., laxatives) or another medical condition except through a mechanism involving constipation.
- The essential feature of __________ is repeated passage of feces into inappropriate places (e.g., clothing or floor) (Criterion A). Most often the passage is involuntary but occasionally may be intentional.
ENCOPRESIS
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2 Categories of Sleep-Wake Disorders
1. Dyssomnias
2. Parasomnias
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Dyssomnias
● Insomnia Disorder
● Hypersomnolence Disorders
● Narcolepsy
● Breathing-related disorders
● Circadian Rhythm Sleep-wake Disorder
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Parasomnias
● Disorder of Arousal
● Nightmare Disorder
● Rapid Eye Movement Sleep Behavior Disorder
● Restless Legs Syndrome
● Substance-Induced Sleep Disorder
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A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
- Dissatisfaction with sleep quantity or quality with complaints of difficulty initiating or maintaining sleep. The sleep complaints are accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning. The sleep disturbance may occur during the course of another mental disorder or medical condition, or it may occur independently.
INSOMNIA DISORDER
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Different Manifestations of Insomnia
1. SLEEP-ONSET INSOMNIA
2. SLEEP-MAINTENANCE INSOMNIA
3. LATE INSOMNIA
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Difficulty initiating sleep at bedtime.
SLEEP-ONSET INSOMNIA
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Frequent or prolonged awakenings throughout the night.
SLEEP-MAINTENANCE INSOMNIA
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Early-morning awakening with an inability to return to sleep.
LATE INSOMNIA
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A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
1. Recurrent periods of sleep or lapses into sleep within the same day.
2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).
3. Difficulty being fully awake after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at least 3 months.
C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.
D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.
- Includes symptoms of excessive quantity of sleep (e.g., extended nocturnal sleep or long naps), sleepiness, and sleep inertia (i.e., a period of impaired performance and reduced vigilance following awakening from the regular sleep episode or from a nap) (Criterion A). Individuals with this disorder generally fall asleep quickly and have a good sleep efficiency (> 90%).
HYPERSOMNOLENCE DISORDER
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A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month:
a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.
b. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.
2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF) hypocretin-1 immunoreactivity values (less than or equal to one-third of values obtained in healthy subjects tested using the same assay, or less than or equal to 110 pg/mL). Low CSF levels of hypocretin-1 must not be observed in the context of acute brain injury, inflammation, or infection.
3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.
- Are recurrent daytime naps or lapses into sleep that occur typically daily but that must occur at a minimum of three times a week for at least 3 months (Criterion A), and are accompanied by one or more of the following: cataplexy (Criterion B1), hypocretin deficiency (Criterion B2), or characteristic abnormalities on a nocturnal polysomnogram or on the MSLT (Criterion B3).
NARCOLEPSY
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Subtypes of Narcolepsy
● Narcolepsy with cataplexy or hypocretin deficiency (Type 1)
● Narcolepsy without cataplexy and either without hypocretin deficiency or with hypocretin unmeasured.
● Narcolepsy with cataplexy or hypocretin deficiency due to a medical condition.
● Narcolepsy without cataplexy and without hypocretin deficiency due to a medical condition.
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A condition that brings on brief bouts of muscle weakness or paralysis.
CATAPLEXY
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(Also known as orexin) is a neuropeptide hormone produced in the hypothalamus that exerts important influences over sleep, arousal, appetite and energy expenditure.
HYPOCRETIN
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The breathing-related sleep disorders category encompasses three relatively distinct disorders:
● Obstructive sleep apnea hypopnea
● Central sleep apnea
● Sleep-related hypoventilation
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A. Either (1) or (2):
1. Evidence by polysomnography of at least five obstructive apneas or hypopneas per hour of sleep and either of the following sleep symptoms:
a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep.
b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.
2. Evidence by polysomnography of 15 or more obstructive apneas and/or hypopneas per hour of sleep regardless of accompanying symptoms.
- Is the most common breathing-related sleep disorder. It is characterized by repeated episodes of upper (pharyngeal) airway obstruction (apneas and hypopneas) during sleep. Each apnea or hypopnea represents a reduction in breathing of at least 10 seconds in duration in adults or two missed breaths in children and is typically associated with drops in oxygen saturation of ≥ 3% and/or an electroencephalographic arousal. Both sleep- related (nocturnal) and wake-time symptoms are common. The cardinal symptoms of _______ _______ _______ _______are snoring and daytime sleepiness.
OBSTRUCTIVE SLEEP APNEA HYPOPNEA
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A. Evidence by polysomnography of five or more central apneas per hour of sleep.
B. The disorder is not better explained by another current sleep disorder.
- Characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort. These are disorders of ventilatory control in which respiratory events occur in a periodic or intermittent pattern.
CENTRAL SLEEP APNEA
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Subtypes of Central Sleep Apnea
- IDIOPATHIC CENTRAL SLEEP APNEA
- CENTRAL SLEEP APNEA WITH CHEYNE-STROKES BREATHING
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Characterized by sleepiness, insomnia, and awakenings due to dyspnea in association with five or more central apneas per hour of sleep
IDIOPATHIC CENTRAL SLEEP APNEA
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Individuals with heart failure, stroke, or renal failure who have central sleep apnea typically have a breathing pattern called _______ _______ _______, which is characterized by a pattern of periodic crescendo-decrescendo variation in tidal volume that results in central apneas and hypopneas occurring at a frequency of at least five events per hour.
CHEYNE-STROKES BREATHING
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A. Polysomnograpy demonstrates episodes of decreased respiration associated with elevated CO2 levels. (Note: In the absence of objective measurement of
CO2, persistent low levels of hemoglobin oxygen saturation unassociated with apneic/hypopneic events may indicate hypoventilation.)
B. The disturbance is not better explained by another current sleep disorder.
- Can occur independently or, more frequently, comorbid with medical or neurological disorders, medication use, or substance use disorder. Although symptoms are not mandatory to make this diagnosis, individuals often report excessive daytime sleepiness, frequent arousals and awakenings during sleep, morning headaches, and insomnia complaints.
SLEEP-RELATED HYPOVENTILATION
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Subtypes of Sleep-Related Hypoventilation
- Idiopathic hypoventilation, also referred to as idiopathic central alveolar hypoventilation, is characterized by reduction of tidal volume and elevated CO2 during sleep, in the absence of any identifiable comorbidity that would account for the hypoventilation.
- Congenital central alveolar hypoventilation is a rare disorder associated with mutation of the gene PHOX2B. It typically manifests at birth.
- Comorbid sleep-related hypoventilation is due to one of numerous potential comorbidities, including pulmonary disease (e.g., chronic obstructive pulmonary disease [COPD]), chest wall abnormalities (e.g., kyphoscoliosis), neuromuscular disease (e.g., amyotrophic lateral sclerosis), and obesity (referred to as obesity hypoventilation), as well as use of medications or substances, especially opioids.
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A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.
B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.
- The delayed sleep phase type is based primarily on a history of a delay in the timing of the major sleep period (usually more than 2 hours) in relation to the desired sleep and wake-up time, resulting in symptoms of insomnia and excessive sleepiness. When allowed to set their own schedule, individuals with delayed sleep phase type exhibit normal sleep quality and duration for age. Symptoms of sleep-onset insomnia, difficulty waking in the morning, and excessive sleepiness early in the day are prominent.
CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS
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Disorders characterized by abnormal behavioral, experiential, or physiological events occurring in association with sleep, specific sleep stages, or sleep-wake transitions. The most common parasomnias are non–rapid eye movement (NREM) sleep arousal disorders and rapid eye movement (REM) sleep behavior disorder.
PARASOMNIAS
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A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:
1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.
2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.
B. No or little (e.g., only a single visual scene) dream imagery is recalled.
C. Amnesia for the episodes is present.
D. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
F. Coexisting mental disorders and medical conditions do not explain the episodes of sleepwalking or sleep terrors.
- The repeated occurrence of incomplete arousals, usually beginning during the first third of the major sleep episode (Criterion A), that typically are brief, lasting 1–10 minutes, but may be protracted, lasting up to 1 hour. The maximum duration of an event is unknown. The eyes are typically open during these events. Many individuals exhibit both subtypes of arousal (i.e., sleepwalking type and sleep terror type) on different occasions, which underscores the unitary underlying pathophysiology.
NON-RAPID EYE MOVEMENT SLEEP AROUSAL DISORDERS
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Repeated episodes of complex motor behavior initiated during sleep, including rising from bed and walking about (Criterion A1). Sleepwalking episodes begin during any stage of NREM sleep, most commonly during slow-wave sleep and therefore most often occurring during the first third of the night. During episodes, the individual has reduced alertness and responsiveness, a blank stare, and relative unresponsiveness to communication with others or efforts by others to awaken the individual. If awakened during the episode (or on awakening the following morning), the individual has limited recall for the episode. After the episode, there may initially be a brief period of confusion or difficulty orienting, followed by full recovery of cognitive function and appropriate behavior.
SLEEPWALKING
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The repeated occurrence of precipitous awakenings from sleep, usually beginning with a panicky scream or cry (Criterion A2). Sleep terrors usually begin during the first third of the major sleep episode and last 1–10 minutes, but they may last considerably longer, particularly in children. The episodes are accompanied by impressive autonomic arousal and behavioral manifestations of intense fear. During an episode, the individual is difficult to awaken or comfort. If the individual awakens after the sleep terror, little or none of the dream, or only fragmentary, single images, are recalled
SLEEP TERRORS
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A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.
B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
E. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of dysphoric dream
- Nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem real and that incite anxiety, fear, or other dysphoric emotions. Nightmare content typically focuses on attempts to avoid or cope with imminent danger but may involve themes that evoke other negative emotions. Nightmares occurring after traumatic experiences may replicate the threatening situation (“replicative nightmares”), but most do not. On awakening, nightmares are well remembered and can be described in detail.
NIGHTMARE DISORDER
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A. Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors.
B. These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps.
C. Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.
D. Either of the following:
1. REM sleep without atonia on polysomnographic recording.
2. A history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (e.g., Parkinson’s disease, multiple system atrophy).
- Repeated episodes of vocalizations and/or complex motor behaviors arising from REM sleep (Criterion A). These behaviors often reflect motor responses to the content of action-filled or violent dreams of being attacked or trying to escape from a threatening situation, which may be termed dream enacting behaviors. The vocalizations are often loud, emotion-filled, and profane. These behaviors may be very bothersome to the individual and the bed partner and may result in significant injury (e.g., falling, jumping, or flying out of bed; running, punching, thrusting, hitting, or kicking).
RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER
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A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:
1. The urge to move the legs begins or worsens during periods of rest or inactivity.
2. The urge to move the legs is partially or totally relieved by movement.
3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night.
B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months.
- Is a sensorimotor, neurological sleep disorder characterized by a desire to move the legs or arms, usually associated with uncomfortable sensations typically described as creeping, crawling, tingling, burning, or itching (Criterion A)
RESTLESS LEGS SYNDROME
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A. A prominent and severe disturbance in sleep.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by a sleep disorder that is not substance/medication-induced. Such evidence of an independent sleep disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non- substance/medication-induced sleep disorder (e.g., a history of recurrent non- substance/medication-related episodes).
SUBSTANCE/MEDICATION-INDUCED SLEEP DISORDER
