DSM 5 First 8 weeks Flashcards
What is a Mental State?
Sensorium
1. a sensory nerve center.
2. the state of an individual as regards to consciousness or mental awareness.
Thoughts
ideas, concepts
Feelings
subjective emotional states
Perceptions
functioning of 5 senses
Cognitions
abilities of intelligence, memory, attention, calculations
Behaviors
actions
outward manifestations of internal mental states
What is a Mental Disorder?
Thoughts delusions, thought disorder
Feelings depression, anxiety, mania
Perceptions hallucinations (5 senses)
Cognitions memory disturbance, orientation
Behaviors compulsions, violence, suicide
Normal versus Abnormal
Clinically significant distress or impairment in social/occupational/relational functioning
Causes suffering
Viewed as “illness” out of the ordinary
Everyone experiences levels of suffering
Problems in living and “mental disorders
Problems: difficulties of every day life
miserable, yet differ in magnitude & impairment
Disorders: significant impairment
consistent
Symptoms & Signs
Symptoms: expressed subjectively
unobservable must be reported
Signs: observable
affect behavior
The DSM: Descriptive vs. Explanatory
No theoretical explanations for psychological events
Describes & categorizes
Describes subjective experience
“Precise description and categorization of abnormal experience”
The Diagnostic Exam
Introduction: how person would like to be addressed?
set expectations; explain interview “What are you hoping to obtain help with?”
Listen: uninterrupted speech guides your MSE
The Diagnostic Exam,History of Present Illness:
“why now”?
last time person felt emotionally well precipitating factors; extenuating circumstances perceived level of impairment
The Diagnostic Exam,Past Psychiatric History:
first notice symptoms?
first sought treatment? hospitalization; how many times, for how long? medications; frequency/dose; effectiveness ECT
The Diagnostic Exam, Safety:
harm to self: previous attempts
history of in family
harm to others: people animals property threats aggression theft
The Diagnostic Exam, Review of Systems
MOOD: have you been feeling sad, blue, irritable, depressed?
loss of interest feeling different than “normal” periods of mood elevation
The Diagnostic Exam:Psychosis:
seeing things, visions, hearing things
people following you special powers: mind reading messages from television/radio
The Diagnostic Exam:Anxiety:
past several months have you frequently worried about a number of things in your life?
objects, places, situations panic or panic attacks
The Diagnostic Exam, Obsessions & Compulsions:
do you frequently experience unwanted thoughts, images or urges?
any physical acts you feel you have to do?
The Diagnostic Exam, Trauma:
worst thing ever happened?
witness/experienced event in which self/others seriously injured? abuse?
The Diagnostic Exam, Dissociation:
trouble remembering?
loss of time feeling detached from body experiencing others as “unreal”
The Diagnostic Exam, Somatic Concerns:
worry; illnesses
The Diagnostic Exam, Eating/Feeding:
appearance; restrictions
The Diagnostic Exam, Sleeping:
inadequate; poor quality
lapses into; increased need unusual behaviors early morning wakening
Mental Status Examination
Appearance
Behavior
Speech
Mood
Affect
Thought Process {Form}
Thought Content
Cognition & Intellectual Resources
Insight & JudgmentNeurodevelopmental Disorders
first appear in early developmental periods
Intellectual Disability Assesses: cognitive capacity (IQ) adaptive functioning New Additions: Communication Disorders Autism Spectrum Disorders
Changes:
Attention-Deficit/Hyperactivity Disorder (lifespan)
Specific Learning Disorder (reading &math etc.)
Inclusions: Motor Disorders
Intellectual Disability Disorder (pg.33)
319 (ICD 9)
(Intellectual Developmental Disorder; ICD terminology)
Deficits: intellectual functioning IQ 70 (two standard deviations from the mean) reasoning problem solving planning abstract thinking judgment academic learning Confirmed by assessment & standardized intelligence testing
Deficits: Adaptive Functioning
does not meet sociocultural & developmental standards for personal independence and social responsibility
limit functioning in 1 or more activities daily life communication social participation independent living
Across multiple environments:
school, home, work, community
Onset: developmental period (before school)
Development & Course
Onset: intellectual/adaptive deficits during developmental period age & characteristics determined by: etiology & severity of brain dysfunction
First 2 years of life; severe intellectual disability: delayed milestones: social motor language
School age: mild disabilities
Neurodevelopmental Disorders
Acquired (rather than genetic) form of ID:
head trauma/TBI
meningitis
encephalitis
When disability secondary to loss of previously acquired cognitive skills: may diagnose both:
Intellectual Disability
Neurocognitive Disorder
Prevalence: 6 per 1000
Males more often diagnosed than females
Neurodevelopmental Disorders
Communication Disorders
Onset: childhood
steady course
usually lifelong functional impairment
Deficits: Speech: expressive production of sounds
Language: form, function & use of symbols Communication: verbal/nonverbal beha
Social (Pragmatic) Communication Disorder
315.39 (F80.89) page 47
Pragmatic language: using language appropriately
(5 yrs. of age)
Persistent difficulties in the social use of nonverbal/verbal communication: (all areas)
deficits in communication for social reasons
difficulty/inability to match communication to context or needs of the listener difficulty following conversation rules difficulties understanding inferences, metaphors
Autism Spectrum Disorder 299.00 (F84.0)
Pg. 50
A. Persistent deficits in social
communication/interaction across multiple
settings
social-emotional reciprocity
nonverbal communicative behaviors developing, maintaining & understanding relationships
Severity: see table 2: page 52
Autism Spectrum Disorder, repetitive patterns of behavior, interests or activities
stereotyped/repetitive motor movements
insistence on sameness; inflexible adherence to routines highly restricted, fixated interests; abnormal in intensity or focus hyper- or hyporeactivity to sensory input
Specify severity: table 2 (page 52)
Autism Spectrum Disorder,
Symptoms present in early developmental period
may not manifest until social demands exceed individual capacity
Clinically significant impairment in social, occupational & other areas of functioning
DSM-IV-TR
autistic disorder
PDD-NOS Autism Spectrum Disorder
Asperger’s
Marked deficits in social communication; no ASD criteria: Social (pragmatic) Communication Disorder
Attention-Deficit/Hyperactivity Disorder pg. 59
A persistent pattern of inattention and/or
hyperactivity-impulsivity which interferes with
functioning or development
Inattention: 6+ sx Inattention cont.
does not follow through on instructions; fails to do home work
difficulty organizing tasks & activities avoids/reluctant/dislikes tasks which require sustained levels of attention looses things easily distracted forgetful \+ months fails to give attention to details; careless mistakes difficulty sustaining attention doesn’t seem to listen when spoken to directly
Attention-Deficit/Hyperactivity Disorder pg. 59
Hyperactivity & Impulsivity: 6+ sx. 6+ mos.
fidgets, taps hands/feet; squirms
leaves seat in seated situations runs/climbs about when not appropriate unable to play quietly; interrupts & intrudes “on the go” “driven by a motor” blurts out answers difficulty taking turns
Attention-Deficit/Hyperactivity Disorder
Several inattentive or hyperactive-impulsive
symptoms were present
prior to age 12
are present in two or more settings
Specifiers: pp. 58-59
Co-Occurring:
language/ motor/social development delays
Associated Features:
irritability, mood lability; low frustration tolerance
Attention-Deficit/Hyperactivity Disorder
Development:
preschool: hyperactivity elementary: inattention adolescence: fidgetiness, jitteriness, restlessness, impatience
More common in males
More likely to develop conduct disorder > antisocial personality disorder
More likely to be: injured/ more accidents
obese
substance use disorders
Tic Disorders: page 81
Tic: sudden, rapid, recurrent, nonrhythmic motor movement or vocalization
Onset: before age 18
Tourette’s Disorder: 307.23 (F95.2)
Persistent (Chronic) Motor or Vocal Tic Disorder
307.22 (F95.1)
Provisional Tic Disorder: 307.21 (F95.0)
Schizophrenia Spectrum & Other Psychotic Disorders
schizotypal personality disorder
delusional disorder
brief psychotic disorder
schizophreniform disorder
substance/medication induced psychotic disorder
psychotic disorder/another medication condition
attain associated with another mental disorder
catatonic disorder due to another medication condition
Schizophrenia Spectrum & Other Psychotic Disorders,Abnormalities in one or more:
delusions
hallucinations disorganized thinking (speech) disorganized(grossly)or abnormal behavior include catatonia negative symptoms
Schizophrenia Spectrum & Other Psychotic Disorders Delusions
persecutory: fear of being harmed
referential: comments/gestures >at oneself
somatic: preoccupation health/organs
erotomanic: other person in love with
grandiose: belief of exceptional abilities
nihilistic: major catastrophe will occur
Schizophrenia Spectrum & Other Psychotic Disorders, Delusions
Bizarre:
impossible; out of cultural realm
typically involves loss of control over mind and/or body thought withdrawal thought insertion delusions of control
Nonbizarre:
plausible; highly unlikely
Schizophrenia Spectrum & Other Psychotic Disorders
Hallucinations
Disturbance in perceptions
no outside stimulus
involuntary
clear & vivid
Auditory: most common
voices (familiar or unfamiliar)
separate from one’s thoughts
Hypnogogic & Hypnopompic
occur while falling to/waking up from sleep
within range of normal experience
Schizophrenia Spectrum & Other Psychotic DisordersDisorganized Thinking (Speech)
Formal thought disorder
inferred by disorganized speech
substantially impairs effective communication derailment/loose associations topic to topic word salad/incoherence tangential answers mildly related
Schizophrenia Spectrum & Other Psychotic Grossly Disorganized or Abnormal Motor Behavior(Includes Catatonia)
Manifestations:
silliness
unpredictable agitation
unable to perform ADLs
Catatonic Behavior:
decreased reactions to environmental stimuli
Negativism- resists directions/instructions
Mutism & stupor- lack of verbal/motor responses
Catatonic excitement: purposeless & excited motor activity
Schizophrenia Spectrum & Other Psychotic Catatonic Features
rigid, inappropriate or bizarre posture
stereotyped movements (stereotypy)
rocking; marching in place, caressing self
crossing/uncrossing legs
staring
grimacing
mutism
echoing of speech
Schizophrenia Spectrum & Other Psychotic
Negative Symptoms
Most prominent in Schizophrenia: diminished emotional expression reductions in expression: face eye contact prosody (rhythm/intonation speech) hand/head/face movements
avolition reduction in self-initiated activities long periods of sitting disinterest in social activities
Schizophrenia Spectrum & Other Psychotic
Negative Symptoms
Alogia: reduction in speech output
Anhedonia: decreased ability to experience pleasure
Asociality: lack of interest in social interactions
Schizophrenia Spectrum & Other Psychotic Disorders presented with gradient of psychopathology
Practitioners:
consider least severe first then review time-limited conditions exclude all other conditions which may present with psychosis.
Schizophrenia Spectrum & Other Psychotic
Assessment Measures
psychiatry.org/dsm5
see page 734
Administer at the initial client/patient interview
Monitors client progress
Level 1 questions: brief survey of 13 domains for adults
12 domains for child and adolescent clients
Level 2 questions: more in-depth assessment of certain domains.
Schizophrenia Spectrum & Other PsychoticSchizophrenia Spectrum & Other Psychotic
Assessment Measures
psychiatry.org/dsm5
see page 734
Severity Measures: disorder specific
correspond to diagnostic criteria
Review Assessment Measures page 742-743:
symptom severity predicts degree of cognitive and/or neurobiological deficits
reviews primary symptoms of psychosis hallucinations disorganized speech disorganized behavior delusions negative symptoms
Schizophrenia Spectrum & Other Psychotic
Delusional Disorder297.1 (F22)
Diagnostic Criteria: page 90
Specify Subtypes: erotomanic grandiose jealous persecutory somatic mixed no one theme predominant unspecified dominant belief not described in types or cannot be clearly determined
Schizophrenia Spectrum & Other Psychotic
Delusional Disorder297.1 (F22)
Specify:
with bizarre content
Course Specifiers:
only use after 1 year duration of the disorder
Severity Specifiers: quantitative last 7 days assesses primary symptoms of psychosis use Assessment Measures (pp. 743-744)
Schizophrenia Spectrum & Other Psychotic
Delusional Disorder
Specify:
with bizarre content
Course Specifiers:
only use after 1 year duration of the disorder
Severity Specifiers: quantitative last 7 days assesses primary symptoms of psychosis use Assessment Measures (pp. 743-744)
Schizophrenia Spectrum & Other Psychotic
Delusional Disorder
Associated Features:
factual insight; not true insight legal difficulties irritable, dysphoric mood litigious/antagonistic behavior anger & violence persecutory jealous erotomanic
Schizophrenia Spectrum & Other Psychotic
Delusional Disorder
More prevalent in adults
May develop schizophrenia
Strong familial relationship:
schizophrenia
schizotypal personality disorder
Functional impairment more limited
relationship distress generally due to delusional beliefs
behavior/appearance “normal”
Schizophrenia Spectrum & Other Psychotic
Brief Psychotic Disorder298.8 (F23)
Diagnostic Criteria: page 94
Subtypes: none
Specify:
with marked stressors
(brief reactive psychosis)
without marked stressors with postpartum onset during pregnancy 4 weeks postpartum
Schizophrenia Spectrum & Other Psychotic
Brief Psychotic Disorder
Associated Features: emotional upheaval rapid, intense affect shifts increase suicide risk (acute episode) severe level of impairment supervision required poor judgment cognitive impairments delusions
Onset:
average age mid 30s
Predisposition: schizotypal/borderline personality disorders
Schizophrenia Spectrum & Other Psychotic
Schizophreniform Disorder
Diagnostic Criteria: pages 96-97
Specify: with good prognostic features two of the following are present *good premorbid functioning *onset of psychotic symptoms within 4 weeks *confusion/perplexity *no blunted/flat affect without good prognostic features
with catatonia
Schizophrenia Spectrum & Other Psychotic
Schizophreniform Disorder
Severity Specifiers
quantitative assessment of primary symptoms of psychosis
Diagnostic Features Schizophreniform Disorder is distinguished from Schizophrenia duration of symptoms at least 1 month less than 6 months
does not have functional impairment requirement
2/3 diagnosed > schizophrenia or schizoaffective
Schizophrenia Spectrum & Other Psychotic
Schizophrenia
Associated Features: inappropriate affect dysphoric mood disinterest in eating depersonalization (disengaged) derealization (surroundings not real) somatic anxiety/phobias sensory processing cognitive deficits
Schizophrenia Spectrum & Other Psychotic
Schizophrenia
Associated Features (cont.)
anosognosia: unaware of illness
{treatment noncompliance}
**aggression: more frequent in males past history of violence, substance, impulsivity
Course Development: late teens – mid 30s first psychotic episode males: early 20s females: late 20s
Schizophrenia Spectrum & Other Psychotic
Schizophrenia
Course Development cont.
onset typically insidious earlier onset > poorer prognosis
Higher risk of suicide
command response
Significant social/occupational impairment
High comorbidity with substance-related disorders
Reduction in life expectancy
Schizoaffective Disorder
Diagnostic Criteria: pg. 105
positive symptoms
AND concurrent major mood episode
Specify:
295.70 (F25.0) Bipolar Type
manic episode
295.70 (F25.1) Depressive Type
with catatonia
Course Specifiers: after one year (pg.106)
Schizoaffective Disorder
Associated Features:
frequent occupational functioning impairment
less severe negative symptoms anosognosia: common (poor insight) increased risk for MDD or BD substance related disorders & anxiety disorders common
Onset: early adulthood
Substance/Medication Induced Psychotic Disorder
Diagnostic Criteria: page 110
Need one or both:
hallucinations
delusions
Specify:
with onset during intoxication
with onset during withdrawal
Severity Specifiers: page111
assess primary symptoms of psychosis
each rated for severity within past 7 days
Substance/Medication Induced
Substances associated with intoxication: alcohol cannabis hallucinogens (includes PCP) stimulants (includes cocaine) anxiolytics inhalants sedatives
With withdrawal:
alcohol hypnotics
anxiolytics “other”
sedatives
