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Flashcards in DSM-5 Dx Deck (45):
1

Social (Pragmatic) Communication Disorder DSM-5

A. Persistent difficulties in social use of verbal and nonverbal communication - must have difficulties in all of following areas:
1. In social communication (greeting people)
2. Changing communication to match context (Using overly formal language)
3. Following rules of conversation and storytelling
4. Understanding what is not explicitly stated (making inferences)

B. The deficits result in functional limitations in effective communication, social participation

C. The onset of sx is in early developmental period but may not become fully manifest until social communication demands exceed limited capacities

Rare among children < 4

2

Autism spectrum disorder - DSM 5

A. Persistent deficits in social communication as manifested by deficits in:
1- Social-emotional reciprocity
2- Nonverbal communication
3- Developing, maintaining, & understanding relationships

B. Restricted, repetitive, patterns of behavior, interests, or activities as manifested by >2 following: [1] stereotyped or repetitive motor movements, [2] inflexible, [3] Restricted fixated interests [4] Hyper or hypoactive to sensory inputs

C. Sx must be present in early developmental period

D. Sx cause clinically significant impairment in social, occupational, or other areas of functioning

E. Rule out other disorders - social pragmatic communication disorder, ADD/ADHD

3

Three presentations of ADHD

[1] Inattention
[2] Hyperactivity and impulsivity
[3] Combined inattentive & hyperactive-impulse

Sx must be seen in two or more settings (home, work, school, friends, family)

4

Social (Pragmatic) Communication disorder - obvious deficits noted

Deficits seen in:

Greeting, sharing info
Tone modulation
Talking differently to adult than child

Speaking differently in a classroom than on playground

Avoiding use of overly formal language

Taking turns, inferences, idioms, humor, metaphors, multiple or abstract meanings

5

DSM 5 Dx ADHD

[1] INATTENTION -
SIX or more of following symptoms for > SIX months:

Fails to pay close attention to details, distracted, loses focus, difficulty with organization, dislikes tasks that require a lot of thinking, loses things, easily distracted, forgetful in ADLs

[2] HYPERACTIVITY AND IMPULSITIVITY
SIX or more of following symptoms for > SIX months:

Fidgets, difficulty remaining seated, child runs about, adults extremely restless, talks excessively, acts as if driven by motor, blurts out answers, interrupts

Note: 17+ YO only need 5 symptoms

6

Psychotic disorders - three groups

[1] Schizophrenia - recurring illness & prone to repeated psychotic episodes

[2] Psychotic mood disorders - mania and depression - schizoaffective disorder

[3] Psychosis a/w neurological condition (acute metabolic & toxic states = delirium - Addison's, Cushing, Dementias (lewy body), folic acid deficiency, pancreatitis, stroke, lupus, temporal lobe epilepsy

7

Delusions: Definition

Fixed beliefs that are not amenable to change in light of conflicting evidence - content may include:

Persecutory: mafia out to get me

Referential: Gestures, comments, environmental cues are directed at oneself (that rock = sign for me from god)

Grandiose: Individual thinks have exceptional abilities, wealth or fame

Nihilistic: World will end

Somatic: Preocupation regarding health or organ function

Delusional jealousy: Spouse unfaithful

Erotomanic: Person of higher status is in love w/ individual

8

Hallucinations

Perception-like experiences that occur WITHOUT external stimulus - vivid & clear, NOT under voluntary control

Audio, visual, gustatory, tactile, olfactory

9

DSM 5 Delusional disorder

1. The presence of one or more delusions with a duration of 1 month or longer.

2. Criterion A for Schizophrenia not met

3. Apart from the impact of the delusions or its ramifications, functioning
is not markedly impaired, and behavior is not obviously bizarre odd.

4. If manic or major depressive episodes - brief relative to the duration of the delusional periods.

5. Many Specifiers – subtypes (grandiose, jealous, somatic) – involve situations that can occur in real life.

The DURATION of impairment is important

10

DSM 5 Dx Brief Psychotic disorder

Presence of one (or more) of the following symptoms. At least one of these must be from 1-2-3
1- Delusions
2 – Hallucinations
3 – Disorganized Speech
4 – Grossly disorganized or catatonic behavior

􏰀 Duration of an episode of the disturbance is at least 1 day but less than 1 month with eventual full return to premorbid level of functioning

􏰀 Disturbance not better explained by MDD or BD

􏰀 Specify stressors, postpartum onset, with catatonia. Note severity

11

Positive psychotic symptoms

Changes in thoughts and feelings that are “added on” to a persons experience – Examples – paranoia, voices, hallucinations, disorganized speech.

12

Negative psychotic symptoms

Things “taken away” or reduced – motivation, intensity of emotions, social withdrawal, poverty of thought.

13

DSM 5 Schizophreniform Disorder

A. Two (or more) of the following, each present for a significant portion of time during a 1 month period ( or less if successfully treated). At least one of these must be 1-2-3. An episode of the disorder lasts at least 1 month but less than 6 months.

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior

5. Negative symptoms (diminished emotional expression, avolition -decrease in the motivation to initiate and perform self-directed purposeful activities. )

􏰀 Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out

14

DSM 5 Schizophrenia

A. Two (or more) of the following, present > 1/2 time > 1 mo At least one of these must be 1-2 or 3

1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (diminished emotional expression)

B. Disturbance in the level of functioning in one or more major areas, such as work, interpersonal relationships, or self care, is markedly below the level achieved prior to the onset. If in childhood or adolescence there is a failure to achieve expected level of the above.

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms)

15

Positive Schizophrenic symptoms

Positive symptoms = symptoms inserted

Delusions and impaired thinking
Hallucinations
Confusion and impaired judgment
Severe anxiety, agitation, and emotional dysregulation

16

Negative Symptoms Schizophrenia

Negative sx = symptoms taken away....

Flat or blunted affect

Poverty of thought

Emptiness and anhedonia

Psychomotor retardation/inactivity

Blunting of perceptions (dull senses – pain)

17

DSM 5 Schizoaffective disorder

An uninterrupted period of illness during which there is a major mood episode (Major Depressive or Manic) concurrent with the Criterion A of Schizophrenia:

Two (or more) of the following, each present for a significant portion of time during a 1- month period (or less if successfully treated). At least one of these must be 1-2 or 3
1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (diminished emotional expression)

The delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness

Schizophrenia + Mood Disorder = Schizoaffective Disorder

18

Comparing Delusional disorder vs brief psychotic disorder, shizophreniform, schizophrenia and szhioaffective

Delusional disorder – 1 month or more – high functioning

Brief Psychotic Disorder – 1 day but less than 1 month. (positive
symptoms)

Schizophreniform – identical to schizophrenia but duration - at least 1 month but not > 6

Schizophrenia – 1 month of active symptoms and then at least 6 months that symptoms are still persistent (negative symptoms).

Schizoaffective Disorder – Schizophrenia with a persistent mood disorder. Simultaneously meeting the diagnostic criteria for schizophrenia and either bipolar disorder or major depressive disorder.

19

Schizophrenia vs delusional disorder

In a delusional disorder the content of the delusions involves events that may actually occur to some people in real life. Bizarre delusions (thought broadcasting, control) and hallucinations, disorganized speech, catatonic behavior, negative symptoms in Schizophrenia. Delusional disorder is usually circumscribed and schizophrenia is more global.

20

Schizophrenia vs Schizoaffective Disorder –

Schizophrenia and Schizoaffective Disorder – psychotic symptoms are the same. Schizoaffective Disorder has the mood component.

21

Schizophrenia vs. Schizophreniform Disorder –

Schizophrenia vs. Schizophreniform Disorder – Primary difference is that schizophrenia lasts for more than six months whereas in schizophreniform disorder the pathology has lasted less than six months.`

22

Schizophreniform Disorder vs. Brief Psychotic Disorder –

Schizophreniform Disorder vs. Brief Psychotic Disorder – Both refer to psychotic disorder of brief duration. Inclusion criteria are broader for brief psychotic disorder listing any one - delusions, hallucinations and disorganized speech vs two of five features Criterion A of schizophrenia. Schizophreniform disorder lasts a least a month and brief psychotic disorder lasts less than a month.

23

Symptoms of Mania

 Persistent mood of euphoria (elevated or expansive mood)
 Grandiosity or elevated self-esteem
 Decreased need for sleep
 Rapid or pressured speech
 Racing thoughts
 Distractibility
 Increased activity or psychomotor agitation
 Behavior that shows expansiveness (lacking restraint in emotional expression), Poor judgment (sexual promiscuity, gambling, buying sprees, giving away money).

24

Symptoms of Hypomania

Hypomania = milder than mania
 Increased energy
 Decreased need for sleep
 Talkative
 Elated, mildly grandiose
 Irritability

25

Symptoms of depression in BP disorder

Mood of sadness, despair, emptiness
Anhedonia
Low self-esteem

Apathy, low motivation, social withdrawal

Excessive emotional sensitivity

Negative, pessimistic thinking
Irritability and low frustration tolerance

Suicidal thoughts (passive or active)

Excessive guilt

Indecisiveness

26

Bipolar I vs Bipolar II

Bipolar I – For a diagnosis it is necessary to meet the criteria for a manic episode. Patients often do not see themselves as ill. Ave 18 yrs of age. Can happen throughout life cycle.

 Bipolar II – For a diagnosis it is necessary to meet the criteria for a current or past hypomanic episode and the criteria for a current or past major depressive episode. Usually present during a depressed episode. Ave onset mid 20’s. First dx as depression. Depression more enduring and disabling over time.

27

Cyclothymia

 Cyclothymia – hypomania with mild/moderate depression. Can convert to Bipolar I or II. Seen adolescents early adult. Children 6.5 yrs`

28

DSM 5 Bipoler I Disorder (Mania part)

A. Abnormally and persistently elevated, expansive, or irritable
mood, lasting at least 1 week and present most of the day, nearly everyday.

B. Three (or more) of the following need to be met:
1. Inflated self-esteem
2. Decreased need for sleep
3. More talkative than usual
4. Flight of ideas, racing thoughts
5. Distractibility
6. Inc in goal-directed activity
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences

29

DSM 5 Bipoler I Disorder (Depression part)

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) anhedonia

1. Depressed mood
2. Anhedonia
3. Significant weight loss
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue
7. Feelings of worthlessness, excessive guilt
8. Can't concentrate
9. Recurrent thoughts of death

30

MDD DSM 5

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
2. Anhedonia
3. Weight loss or gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue
7. Feelings of worthlessness, excessive guilt
8. Can't concentrate
9. Recurrent thoughts of death

31

Persistent depressive disorder (Dysthymia)

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.

B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self esteem.
5. Poor concentration or difficulty making decisions.
6. Feeling of hopelessness.

C. During a 2-year period (1 year child/adolescents) of the disturbance the individual had never been without symptoms in Criteria A and B for more than 2 months at a time.

Note - Children and adolescents, mood can be irritable and duration must be at least 1 year.

32

PMDD DSM 5

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 with a few days after the
onset of menses, and become minimal or absent in the week postmenses.

One or more of the following:
 Affective lability – moody, sad, tearful
 Irritability or anger – increased interpersonal conflicts
 Depressed mood
 Anxiety, tension or feelings of being on edge One or more of the following (total of 5):
 Decreased interest – anhedonia
 Subjective difficulty in concentration
 Lethargy, lack of energy
 Change in appetite, overeating, food cravings
 Hypersomnia or insomnia
 Feelings of being overwhelmed or out of control
 Breast tenderness, swelling , joint or muscle pain, bloating or weight gain

The above cause distress or interfere with work, school, relationshipsv

33

Medications PMDD

Sarafem, Paxil, Zoloft

34

Disruptive Mood Dysregulation Disorder (DMDD)

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.

B. The temper outbursts are inconsistent with developmental level (e.g., the child is older than you would expect to be having a temper tantrum).

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, friends).

Above present > 1 yr. No relief from sx > 3 mo. Present in 2 or more settings.

The diagnosis should not be made for the first time before age 6 years or after age 18. Age of onset of these symptoms must be before 10 years old.

35

DMDD Treatment

Psychotherapy - CBT
Parent training

36

CBT Two Tasks

[1] Cognitive restructuring - change thinking patterns

[2] Behavioral activation - patients learn to overcome obstacles to participating in enjoyable activities

CBT focuses on immediate present - what and how a person thinks more than why a person thinks that way. Focuses on specific problems. CBT is goal oriented.

37

DSM 5 Separation Anxiety Disorder

A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:

1. Distress when separation

2. Persistent excessive worry about possible harm to major attachments

3. Persistent excessive worry that event will lead to separation from major attachment

4. Persistent refusal to go away from home, school, to work or elsewhere because of fear of separation

5. Excessive fear of being alone without major attachment figure

6. Persistent refusal to go to sleep without being near major attachment

7. Repeat nightmares involving theme of separation

8. Complaints of physical symptoms (HA, stomach ache, N/V)

B. The duration of sx is >4wk in children & >6 months in adults

C. Causes impairment in social, academic, occupational functioning

38

DSM 5 Selective Mutism

A. Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations

B. The disturbance interferes with educational or occupational achievement or with social communication

C. The duration of the disturbance is at least 1 month

D. The failure to speak is not attributable to lack of knowledge or comfort with ,
the spoken language required in the social situation.

Children speak at home but not out socially or school.
Excessive shyness, fear of social embarrassment, social isolation withdrawal, clinging.

39

DSM 5 Specific Phobia

A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response. In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.

C. The phobic object or situation is avoided.

D. The fear or anxiety is out of proportion to the danger posed by the object.

E. The fear, anxiety, or avoidance is persistent lasting for 6 months or more. The fear causes distress or impairment

40

Treatment Specific Phobia

Exposure therapy - involves the exposure of the patient to the feared object in a safe setting. Small steps - Elevators – airplanes.

41

DSM 5 Social Anxiety Disorder

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. (being observed eating, giving a speech). With children should be in the peer setting.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (humiliating or embarrassing ; rejected by others).

C. The social situations almost always provoke fear or anxiety. – Children fear 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. Fear is out of proportion to actual threat posed. Lasts for 6 months or more. Median age 13 years old.

42

DSM 5 Panic Disorder

A. 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 with time four (or more) of the following symptoms occur:
1. Palpitations, pounding heart, or accelerated heart rate
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea, ABD pain
8. Feeling dizzy, unsteady, light-headed or faint.
9. Chills or heat sensations.
10. Paresthesia's (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalizations (being detached from one self).
12. Fear of losing control or “going crazy”
13. Fear of dying.

Note the abrupt surge can occur from a calm state or an anxious state

B. At least one of the attacks have been followed by 1 month (or more) of one or both of the following.

1. Persistent concern or worry about additional panic attacks or their consequences.
2. A significant maladaptive change in behavior related to the attacks (avoidance).

43

DSM 5 Agoraphobia

A. Marked fear or anxiety about two (or more) of the following five situations:
1. Using public transportation (care, bus, train, ship, planes)
2. Being in open spaces (parking lots, supermarkets, bridges)
3. Being in enclosed places (shops, theaters)
4. Standing in line or being in a crowd
5. Being outside of the home alone

B. 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 (incontinence).

C. Situations almost always provoke fear or anxiety. Actively avoided or require the presence of a companion. Fear is out of proportion to the actual danger Lasting for 6 months or more.

44

DSM 5 GAD

A. Excessive anxiety and worry, occurring more days than not for at least 6 months (work and school).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms, with at least some symptoms having been present for more days than not for the past 6 months. (One item for 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, staying asleep or restless, unsatisfying).

D. Causes significant distress or impairment in important area of functioning.

45

DSM 5 OCD

Obsessions as defined by:
1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that 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.

Compulsions as defined by:
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive