DSM-V Flashcards
(40 cards)
DSM-V Criteria for Schizophrenia
A = ≥2 of the following, present for a significant portion of time during a 1 mo period (less if successfully treated). At least one of these must be (1), (2), or (3)
- Delusions
- Hallucinations
- Disorganized speech (e.g. frequent derailment or incoherence)
- Grossly disorganized or catatonic behaviour
- Negative symptoms
(i. e. diminished emotional expression or avolition)
B = ↓ level of function: for a significant portion of time since onset.
- One or more major areas affected (e.g. work, interpersonal relations, self-care) is markedly decreased
- If childhood/adolescent onset, failure to achieve expected level
C = at least 6 mo of continuous signs of the disturbance. Must include at least 1 mo of symptoms that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms
(the disturbance may manifest by only negative symptoms or by two or more Criterion A symptoms present in an attenuated form - e.g. odd beliefs, unusual perceptual experiences)
D = Exclude schizoaffective disorder and depressive or bipolar disorder with psychotic features
E = Exclude other causes: GMC, substances (e.g. drug of abuse, medication)
F = If history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 mo
DSM-V Schizoaffective disorder
A – An uninterrupted period of illness where there is concurrent psychosis (criterion A of schizophrenia) and major mood episode.
B - delusions or hallucinations for ≥ 2 weeks in the absence of a major mood episode during the lifetime duration of the illness
C - major mood episode symptoms are present for the majority of the total duration of the active and residual periods of the illness
D - the disturbance is not attributable to the effects of a substance or another medical condition
note: difference between schizophrenia and schizoaffective disorder is that schizoaffective disorder has a prominent MOOD component (manic or depressed) as apposed to schizophrenia where mode symptoms may present but they are NOT prominent
DSM-V criteria Brief Psychotic Episode
A psychotic illness that meets criteria A + D + E of schizophrenia BUT with a very short duration of symptoms (1day - <1m total) with eventual resolution to full pre-morbid functioning. If the symptoms extend past 1 month, it become schizophreniform disorder.
Managed with secure environment, antipsychotics and anxiolytics. This condition is self-limiting and has a good prognosis. Most return to normal pre-morbid functioning within a month.
DSM-V for Schizophreniform disorder
A psychotic illness that meets criteria A + D + E of schizophrenia BUT with a shorter duration of symptoms (1 -6m total). If the symptoms extend past 6 months, it become schizophrenia.
Full rapid resolution of symptoms is associated with better prognosis. Can develop into schizophrenia.
DSM-V for a Delusional disorder
A = The presence of one (or more) delusions with a duration of 1 mo or longer
B = Criterion A for schizophrenia has never been met
Note: hallucinations, if present, are not prominent and are related to the delusional theme
C = Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour is not obviously bizarre or odd
D = If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods
E = The disturbance is not attributable to the physiological effects of a substance, another medical condition or mental disorder
DSMV Depressive episode
A = ≥ 5 of the following have been present during the same 2 week period and represent a change from previous functioning: (one must be low mood or anhedonia)
a. Depressed Mood most of the day, nearly every day as indicated by either subjective report (empty, sad, hopeless) or observation
b. Markedly diminished Interest or pleasure in all, or almost all activities most of the day, nearly every day
c. Significant weight loss / gain (e.g., ≥ 5% of body weight in a month) or decrease or increase in Appetite nearly every day
d. Insomnia or hypersomnia nearly every day (Sleep)
e. Psychomotor agitation or retardation nearly every day
f. Fatigue or loss of Energy nearly every day
g. Feelings of worthlessness or excessive or inappropriate Guilt nearly every day
h. Diminished ability to think or Concentrate or indecisiveness nearly every day
i. Recurrent thoughts of death (suicidal ideations +/- plan or suicide attempt)
B = Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
C = Episode is not attributable to physiological effects of a substance or to another medical condition
“MSIG E CAPS”
DSMV Manic Episode
For Bipolar, one must meet the following criteria of a manic episode (at least 1 episode in lifetime)
A = 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 + present most of the day, nearly every day
B = During the period of mood disturbance and ↑ energy or activity, ≥3 of the following are present to a significant degree and represent a noticeable change from usual behaviour
a. Inflated self-esteem (Grandiosity)
b. Decreased need for sleep
c. More talkative than usual or pressure to keep
talking
d. Flight of ideas or subjective experience that thoughts are racing
e. Distractibility
f. Increase in goal directed Activity or psychomotor agitation
g. Excessive involvement in Activities that have a high potential for Painful consequences
C = The mood disturbance is sufficiently severe to cause marked impairment for social or occupational functioning or to necessitate hospitalisation to prevent harm to self or others, or there are psychotic features
D = The episode is not attributable to physiological effects of a substance or to another medical condition
DSM-V Hypomanic episode
▪ Same as above but not severe enough to cause marked impairment for social or occupational functioning
▪ It is associated with an unequivocal change in functioning that is uncharacteristic of individual when not symptomatic
▪ Disturbance in mood and the change in functioning are observable by others
Bipolar subtype 1
▪ 1 or more manic or mixed episodes have occurred
▪ Commonly accompanied by at least 1 MDE (but not needed for diagnosis)
▪ If the patient needs hospitalisation or has psychotic symptoms it’s BPAD I
▪ Disorder may become apparent after a patient is given a course of antidepressant
monotherapy for their depressive symptoms.
Bipolar subtype 2
▪ 1 or more hypomanic episodes (4 or more weeks) AND 1 or more major depressive episodes
▪ BPAD II is often under diagnosed + under reported as the MDEs are long and there is poor recognition of hypomanic episodes
Cyclothymia
▪ Alternating between hypomanic and mild/moderate depressive symptoms for at least 2 years (never without symptoms for more than 2 months)
▪ These people have never reached criteria for an MDE, manic or hypomanic eps.
▪ Patients are higher functioning but the symptoms still cause distress or impairment
in important areas of functioning.
▪ Management is the same as BPAD I = mood stabiliser +/- psychotherapy, avoid
antidepressant monotherapy, address substance use.
Dysthymia
▪ Long standing depressed mood but does not fulfil criteria for recurrent depressive disorder. They feel tired + depressed and everything is an effort
DSM V Adjustment Disorder - Criteria, Clinical Presentation and Management Plan
CRITERIA/ CLINICAL PRESENTATION
(A) Development of emotional or behavioural symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor
(B) These symptoms / behaviours are clinically significant as evidenced by either of the following:
• Marked distress that is in excess of what would be expected from exposure to the stressor
• Significant impairment to social/occupational/academic functioning
(C) The stress-related disturbance does not meet criteria for another mental disorder nor is it an exacerbation of a pre-existing mental condition
(D) The symptoms do not represent normal bereavement
(E) Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months
SPECIFIERS
o With depressed mood, with anxiety, with mixed anxiety/depression, with conduct disturbance (e.g. reckless driving,), unspecified
RISK FACTORS / Stressor types
▪ An individual’s personality and vulnerability to stress play an important contributing role
▪ SINGLE = termination of relationship, loss of a loved one, loss of job
▪ MULTIPLE = marked business difficulties, marital problems
▪ RECURRENT = seasonal business crisis
▪ CONTINUOUS living in a dangerous neighbourhood, new stoma, dialysis
▪ DEVELOPMENTAL EVENTS = going to school, leaving parental home, getting married, becoming a parent, failing occupational goals, retirement
MANAGEMENT PLAN/APPROACH
Non-Pharmacological
▪ Brief psychotherapy
= Individual or group
= Group good for those with specific medical conditions
▪ Crisis intervention
▪ Education + social supports
▪ Refer to online + written resources Pharmacological
▪ Short course of benzodiazepines for those with significant anxiety symptoms (low- dose, limited duration)
DSM-V Acute Stress Disorder - Criteria, Clinical Presentation and Management Plan
CRITERIA
(A) Exposure to actual or threatened death, serious injury or sexual violence in one
of the following ways: direct experience, witnessing, learning about events happened to a close friend / family member, repeated/extreme exposure to adverse details of traumatic events (e.g. first responders, police officers)
(B) Have ≥9 of the following symptoms of any of these 5 categories:
▪ Intrusion symptoms (dreams, flashbacks, distress, memories)
▪ Negative Mood
▪ Dissociative symptoms (dazed, time slowing, 3rd person, amnesia)
▪ Avoidance symptoms (of the memory or of people)
▪ Arousal symptoms (insomnia, irritability, hyper-vigilance etc.)
(C) Duration is 3days – 1 month after trauma exposure. (symptoms usually begin immediately after trauma and persist for at least 3 days, or up to a month)
(D) The disturbance causes clinically significant distress or impairment in social, occupational or academic functioning
(E) Condition is not attributable to drugs, other mental health disorder or organic illness.
MANAGEMENT PLAN/APPROACH–>Aim = manage distress and prevent PTSD
Psychological First Aid
▪ Ensuring person’s safety + support (provide medical care if needed)
▪ Acknowledge the stress reaction
▪ Provide information about event + resolution
▪ Offer practical assistance
▪ Assess suicide risk, risk to others + dependants
▪ One off debriefing is NOT recommended as they can increase symptoms and
are not effective in treating ASD or preventing PTSD.
Psychology Inputs
▪ Psychoeducation to understand ASD and encourage use of inherent strengths, support networks and positive judgement.
▪ Understanding of adaptive mechanisms and developing coping mechanisms
▪ Cognitive behavioural therapy (good to decrease symptoms and ways to deal with
future events)
▪ Fostering + enhancing the therapeutic alliance
Pharmacotherapy in select situations (Senior Doctor Discretion)
▪ SSRIs for intrusive thoughts or low mood
▪ Benzodiazepines for anxiety + insomnia
▪ Anticonvulsants or Beta blockers may be helpful in some symptom clusters but this is
at the specialist’s discretion
DSM V PTSD – Criteria, Clinical Presentation and Management Plan
CRITERIA
A) EXPOSURE to actual or threatened death, serious injury or sexual violence in one of the following ways: direct experience, witnessing, learning about events happened to a close friend / family member, repeated/extreme exposure to adverse details of traumatic events (e.g. first responders, police officers)
(B) Presence of ≥1 of the following INTRUSION SYMPTOMS associated with the traumatic event (has started after the event):
o Involuntary / recurrent / intrusive memories
o Involuntary / recurrent / intrusive dreams (event or affect)
o Dissociative sx / flashbacks feeling like event is reoccurring
o Intense / prolonged psychological distress at internal or external stimuli
that resemble the event
o Intense / prolonged physiological distress at internal or external stimuli
that resemble the event
(C) Persistent AVOIDANCE OF STIMULI associated with the event, as evidenced
by one or both of the following:
o Avoids distressing memories / thoughts / feelings re: the event
o Avoids external reminders (people, places, conversations, activities, objects
etc.) that arouse distressing memories / thoughts / feelings re: the event
(D) NEGATIVE ALTERATIONS in conitions + mood associated with the event, as
evidenced by ≥2 of the following:
o Amnesia re: event or parts of the event
o Negative beliefs or expectations about oneself, others, or the world
o Distorted cognitions about the cause or consequences of the event that lead
the individual to blame them self or others
o Negative emotional state (e.g. fear, horror, anger, guilt, or shame)
o Markedly diminished interest or participation in significant activities o Feelings of detachment or estrangement from others
o Persistent inability to experience positive emotions
(E) Marked alterations in AROUSAL + REACTIVITY associated with the event, as evidenced by ≥2 of the following:
o Irritable behaviour and angry outbursts - typically verbal or physical aggression
o Reckless or self-destructive behaviour o Hypervigilance
o Exaggerated startle response
o Problems with concentration
o Sleep disturbance (e.g. difficulty falling or staying asleep or restless sleep)
(F) DURATION symptoms last > 1 month (occur within 6mo of event)
(G) Causes clinically significant distress or impairment
(social/occupational/academic)
(H) Condition is not attributable to drugs, other mental health disorder or organic
illness.
Men’s trauma is most commonly combat experience/physical assault; women’s trauma is usually physical or sexual assault
COMPLICATIONS / ASSOCIATED ISSUES
▪ Substance abuse
▪ Relationship difficulties
▪ Depression
▪ Impaired social and occupational functioning
▪ Personality disorders (esp. Borderline PD)
MANAGEMENT PLAN/APPROACH
PSYCHOTHERAPY
▪ Ensure safety and stabilize: emotional regulation techniques (e.g. breathing, relaxation)
▪ Once coping mechanisms established, can explore/mourn trauma - challenge dysfunctional beliefs, etc.
▪ Reconnect and integrate - exposure therapy, etc.
PHARMACOLOGICAL
▪ SSRIs (e.g. paroxetine, sertraline)
▪ Prazosin (for treating disturbing dreams and nightmares)
▪ Benzodiazepines (for acute anxiety)
▪ Adjunctive atypical antipsychotics (risperidone, olanzapine)
EYE MOVEMENT DESENSITISATION + REPROCESSING (EMDR)
▪ an experimental method of reprocessing memories of distressing events by
recounting them while using a form of dual attention stimulation such as eye
movements, bilateral sound, or bilateral tactile stimulation
▪ Its use is controversial because of limited evidence
DSM-V - Generalised Anxiety Disorder: Criteria, Treatment
CRITERIA / PRESENTATION
(A) Excessive anxiety + worry (apprehensive expectation), for more days than not for 6 months re: a variety of activities / events
(B) Difficult to control the worry
(C) Associated with ≥ 3 of the C-FIRST symptoms
(D) Clinically significant impairment of function
(E) Condition is not attributable to drugs, other mental health disorder or organic illness.
TREATMENT
- Similar to panic disorder
- EXCLUDE ORGANIC ILLNESS
= Thyroid ↑, caffeine, stimulants, alcohol withdrawal
= Adjustment disorder with anxious mood
= If older person, think depression ot dementia with anxious mood
- LIFESTYLE = ↓ caffeine = Good sleep hygiene = Avoid alcohol and other drugs (must explore this area as many patients self-medicate)
- PSYCHOTHERAPY (first line!!)
= psychoeducation
= CBT = interoceptive exposure (eliciting panic attack symptoms and learning how to tolerate them with coping strategies)
= Stress management = scheduling, problem focused counselling
= Relaxation techniques - MEDICATIONS (if therapy alone is not enough)
= 1st line – SSRIs / SNRIs (paroxetine, escitalopram, sertraline, duloxetine, venlafaxine)
= 2nd line – buspirone (TID), buproprion (caution stimulating SEs)
= Don’t need high doses usually
= Add Benzodiazepines if needed (short-term, low dose, regular schedule, long half-life, avoid prn usage)
= DO NOT USE BETA-BLOCKERS
NOTE: C-First Symptoms Concentration Fatigue Irritability Restless Sleep Disturbance Tension (muscle)
PHOBIC DISORDERS - Key criteria
KEY CRITERIA
- Exposure to the stimulus provokes an immediate anxiety response (?even panic attack)
- Person recognises fear as excessive / unreasonable
- Situations are avoided or endured with great stress/ distress/ anxiety
- Significant interference with daily routine,/occupational/social functioning. Patient has
marked distress.
SOCIAL ANXIETY DISORDER - Criteria
- Marked + persistent (>6 months) fear of social or performance situations in which one is exposed to unfamiliar people or possible scrutiny of others. They fear that they will act in a way that may be humiliating or embarrassing
- The phobic situation(s) is avoided or is endured with intense anxiety or distress.
- E.g. public speaking, initiating / maintaining conversation, dating, eating in public
Generalised Social Anxiety
- Psychological – CBT, social skills training
- Medications – SSRI best (need for ~ 6 – 12 weeks)
Non- Generalised Social - Anxiety
- Control of hyperventilation + Deep breathing
- Cognitive strategies
- Propranolol to manage specific symptoms
Agoraphobia - Definition, Criteria, management
The fear and avoidance of being in places or situations from which escape might be difficult or embarrassing, or in which help might not be available in the event of suddenly developing a symptom that could be incapacitating or embarrassing. Most people with agoraphobia develop this in response to panic attacks.
CRITERIA (A) Marked fear / anxiety re: 2/5 --> Using public transport --> Being in open spaces --> Being in closed spaces --> Standing inline or being in a crowd --> Being outside home alone
(B) ear that person fears / avoids situations because of thoughts that escape may be difficult or help will be unavailable should panic symptoms arise
(C) Situations provoke anxiety
(D) Situations are actively avoided, need a companion or are endured
(E) The fear is out of proportion
(F) The fear / anxiety / avoidance causes functional impairment or distress
(G) Exclude organic or other MH issue (esp. obsessions, perceived flaws in appearance, PTSD, separation anxiety, paranoia)
Management
- Panic Disorder
- Manage panic attacks
- Behavioural therapy with graduated in vivo exposure to overcome the phobic avoidance
Panic Attack Criteria/ definition
DEFINITIONS / CRITERIA
PANIC ATTACK = an abrupt surge of intense fear or discomfort that reaches a peak within minutes. During this time one experiences ≥4 of the following symptoms: Mnemonic – STUDENTS FEAR 3CS
Sweating Trembling Unsteady/ dizzy Depersonalisation/ derealisation Excess HR/ palpitation Nausea Tingling/parasthesia SOB
FEAR- of dying, losing control, of going crazy
Chest pain
Chills or heat
Chocking feeling
NOTE: A panic attack is NOT a DSM-V disorder as it can occur in the context of other conditions.
PANIC DISORDER - Criteria, Exclusions, DDx, Management
Definition = have panic attacks that have no apparent trigger + experience ≥ 1 month of anxiety about the panic attacks (persistent concern, anticipation, avoidance or significant maladaptive change).
This is a DSM-V disorder.
Exclusions
- not attributable to medications, substance use, organic illness or other mental health disorder.
DDX o Amphetamine, cocaine o Alcohol withdrawal o Opioid withdrawal o Arrythmia o Hypoglycemia o Cushings/ steroids o Hyperthyroidism o PE
TREATMENT
Lifestyle
- Explain why panic symptoms arise
- Offer support + stress management
- Limit caffeine and stimulant drinks
- Good sleep hygiene
- Advise that 50% - 80% improve with treatment, but most people have a chronic
course and will need help to deal with psychological stressors
Psychological
- Relaxation techniques
= Visualisation
= Controlled breathing techniques, box breathing
(help alleviate ↓PCO2 and the associated symptoms)
= Progressive muscle relaxation
- CBT = interoceptive exposure (eliciting panic attack symptoms and learning how to
tolerate them with coping strategies) - Cognitive restructuring = address beliefs re: panic attacks
Pharmacological
- FIRST LINE: (if CBT alone is not sufficient)
= SSRIs – Fluoxetine, citalopram, paroxetine, fluvoxamine, sertraline
= SNRIs – venlafaxine
= May have transient increase in anxiety in first days but this resolves
= Key SEs – GIT, flushing, sexual dysfunction, drowsy, dry mouth,
= 2nd Line (TCAs, MAOIs and some benzoes)
- Rules of thumb
= Start low, go slow, aim high
= Explain symptoms to expect prior to initiation (prevent non-compliance due to SEs)
= Usually need high doses + longer therapy than depression (e.g. 12 wks) to see effect
= Keep medicated for 6m - 1 year to avoid relapse (the can try stopping) - If Benzodiazepines needed short-term (1m max), low dose, regular schedule, long half-life, avoid prn usage
- Try to avoid bupropion or TCAs - stimulating effects (exacerbate anxious symptoms)
OCD - Criteria, Management
CRITERIA / PRESENTATION
(A) Has obsessions / compulsions or both
*OBSESSIONS
= Recurrent / persistent thoughts, impulses or urges that are intrusive and unwanted. They cause marked anxiety or distress
= Person tries to ignore or supress the urge or neutralise them with another action (i.e. the compulsion)
*COMPLULSIONS = Repetitive stereotyped behaviours (e.g. hand washing, door closing) or mental acts (e.g. praying, repeating words) that the person feel driven to perform in response to an obsession or in accordance to rules that must be applied
= The acts are aimed at reducing the or preventing anxiety and distress from the situation. However, the compulsions are not connected in a realistic way or are clearly excessive
(B) The obsessions / compulsions are time consuming (>1hr / day) or cause clinically significant distress and impairment of functionality
(C) Condition is not attributable to drugs, other mental health disorder or organic illness.
MANAGEMENT
BEST = psychotherapy and pharmacotherapy
PSYCHOTHERAPY
- Cognitive Behavioural Therapy
= Exposure with response prevention (exposure to fear situations with
addition of how to prevent and challenge underlying beliefs)
MEDICATIONS
- Serotonergic drugs work best.
- SSRIs / SNRIs
= need high dose + long duration – 12 – 18 week trials
= if the condition improves and becomes stable, he medications can be
reduces slowly and then stopped
= they are best managed by a psychiatrist - Adjunctive antipsychotics in severe cases
Controlled / Measured Breathing
Progressive Muscle Relaxation
When relaxed we take slow breaths, but when in anxious state we breathe shallow and rapid. Measured breathing helps us regulate and calm the body / brain. Can use this in times of stress. It is good to practice for a few mins every night.
1. Relax shoulders, legs, jaw etc.
2. Breathe in slowly through nose for a
count of 4 (can be 5 – 10 if able)
3. Hold the breath for 4 seconds
4. Exhale slowly and smoothly through
pursed lips (like a straw) over a count of
4
5. Repeat until feel calm
In panic reaction muscle tension increases leading to stiffness and pain. PMR helps to become aware of this tension and address it.
1. Find private location to sit or lay down
2. Begin taking deep breaths in and
“breathing the tension out”
3. Beginning at the feet, tense the muscles
of the toes up – hold for 5 seconds and notice the feeling of tension release feel the relaxation
4. Continue up the legs, buttocks, fingers, hands, arms, back, neck, face
Cluster A - Weird/ MAD = general decryption of category
o Patients are odd / eccentric / withdrawn
o Familial Association (family Hx) with PSYCHOTIC DISORDERS
o Higher risk of developing schizophrenia
o Defence mechanisms = intellectualisation + projection + magical thinking
Paranoid Personality Disorder
Criteria
Parenting
Defense
Pervasive distrust and suspiciousness of others; interpret motives as malevolent, beginning by early adulthood and presenting in variety of contexts with ≥4 Sx (SUSPECT)
S- Spousal infedility suspected
U- Unforgiving (bears grudges)
S- Suspect others of exploiting/decieving them
P - Percieves attacks on character (+reacts quickly)
E - Enemy or friend? (preoccupied with trustworthiness)
C- Confiding in others is feared
T - Threats interpreted in benign remarks/events
Parenting
- Harsh + punitive
Defence Mechanism
- Projection
- Identification with the aggressor
- Repression
- Denial
- Denial
