Final (DSM) Flashcards
Selective Mutism - Associated Features (6)
Shyness Fear of embarrassment
Social Isolation/Withdrawal
Clinging
Tantrums/Oppositional Behavior
Often comorbid with social anxiety
Occasionally comorbid with communication disorder
Specific Phobia Specifiers
Animal
Natural
Environment
Blood-Injection-Injury
Situational
Other
Selective Mutism Etiology, Risk and Prognostic Factors
Temperament
-Negative affectivity and behavioral inhibition
Environment
-Social inhibition, overprotective and controlling behavior among parents
Genetics
-Shared genetic factors with social anxiety disorder
MDD Prevalence
Lifetime 12-20%
12 month in US: 7%
Male to female 1:2
-but no difference in symptoms, course, treatment response, or functional consequences
Onset can occur at any age, with increased risk after puberty, and incidence peaking in the 20s
Obsessions (OCD)
recurrent or persistent thoughts, urges, or images that are experienced as intrusive and unwanted and caused marked anxiety and distress
Types: Taboo (aggressive/violent/sexual), Symmetry, Harm to self/others, Religious, Contamination, Doubt
Social Anxiety Disorder - Prevalence, Development, and Course
7% Prevalence
- lower for older adults
- more pronounced in adolescents/young adults
1. 5-2x more common in females - Females: comorbid with depressive, biopolar, and anxiety disorders
- Males: comorbid with ODD/CD and substance use
Majority (~75%) have onset between 8-15 years
-first onset in adulthood is rare
Onset may follow stressful/humiliating event
30% experience remission in 1 year
About half seek treatment
Trung gio
(“hit by the wind” or “to catch wind”)
Found among Vietnamese Panic attack (associated with headaches, feeling unwell) experienced after walking into a windy environment
- May attribute attack to exposure to wind
- May avoid atmospheric wind
MDD - Differential Diagnosis - ADHD
Distractibility and low frustration tolerance can occur in both attention-deficit/ hyperactivity disorder and a major depressive episode; if the criteria are met for both, attention-deficit/hyperactivity disorder may be diagnosed in addition to the mood disorder. However, the clinician must be cautious not to overdiagnose a major depressive episode in children with attention-deficit/hyperactivity disorder whose disturbance in mood is characterized by irritability rather than by sadness or loss of interest.
Separation Anxiety Disoder Criteria (4)
A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
- Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
- Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
- Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
- Repeated nightmares involving the theme of separation.
- Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.
B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.
C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.
D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized
Anxiety Disorders DSM-IV
Anxiety disorders in the DSM-IV were split into three categories in the DSM-5:
Anxiety Disorders
Obsessive Compulsive Disorder
PTSD & Acute Stress Disorder
Body Dysmorphic Disorder Criteria (4)
A. Preoccupation with one or more perceived defects or flaws in physical appearance that
are not observable or appear slight to others.
- often try to change how they look
- excessive fixation on defect
B. At some point during the course of the disorder, the individual has performed repetitive
behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking)
or mental acts (e.g., comparing his or her appearance with that of others) in response
to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or
weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
Panic Disorder - Prevalence
Panic Attacks: 11.2% adults in US in last year
-30% had at least one PA in lifetime
Panic Disorder: 2-3% adults/adolescence
Panic Disorder Criteria (4)
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 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.
- Paresthesias (numbness or tingling sensations).
- Derealization (feelings of unreality) or depersonalization (being detached from oneself).
- Fear of losing control or “going crazy.”
- 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.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive-compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).
Severity specifiers - depressive disorders
Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability.
Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.
Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”
Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.
Excoriation Disorder Criteria (5)
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine)
or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental disorder (e.g.,
delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived
defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic
movement disorder, or intention to harm oneself in nonsuicidal self-injury).
Disruptive Mood Dysregulation Disorder Criteria (11)
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.
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, peers).
E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D.
F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these.
G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
H. By history or observation, the age at onset of Criteria A-E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.
Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.
J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).
Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.
OCD Etiology and Risk Factors
Genetics
-First degree relatives have 6x risk of developing OCD
Biology
-Brain differences: the caudate nucleus and orbitofrontal cortex
Environment
-Child abuse/trauma, life stressors, family maintenance
Agoraphobia Prevalence
- 7% adults and adolescents
- less common in childhood and older adults
Major Depressive Disorder Specifiers
Severity/Course (based on number and severity of symptoms): Mild Moderate Severe
With psychotic features
In partial remission
In full remission
Unspecified
Other specifiers:
With anxious distress
With mixed features
WIth melancholic features
With atypical features
WIth mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset (aka postpartum depression)
With seasonal pattern
Major Depressive Disorder Criteria (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.
Note: Do not include symptoms that are clearly attributable to another medical condition.
- 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.)
- 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).
- 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.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- 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.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the physiological effects of a substance or to another medical condition.
Note: Criteria A-C represents a major depressive episode.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic episode or a hypomanic episode. Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.
Panic Disorder - Etiology, Risk, Prognostic Factors
Genetics/physiological
- Family history
- Respiratory problems (e.g. asthma)
- Amygdala response (activates sympathetic nervous system)
Temperament
- Negative affectivity, anxiety sensitivity
- History of limited-symptom attacks
Environment
- Childhood history of abuse
- Smoking
- Life stressors
Social Anxiety Disorder - Associated Features
Lack of assertiveness
Poor body language and nonverbal
Shy/withdrawn Blushing
Live at home longer
Limit employment opportunities
Substance use
Persistent Depressive Disorder - Criteria B Symptoms (6)
- Poor appetite or overeating.
- Insomnia or hypersomnia.
- Low energy or fatigue.
- Low self-esteem.
- Poor concentration or difficulty making decisions.
- Feelings of hopelessness.
Premenstruel Dysphoric Disorder - Criteria B Symptoms (4)
- Marked affective lability (e.g., mood swings: feeling suddenly sad or tearful, or increased sensitivity to rejection).
- Marked irritability or anger or increased interpersonal conflicts.
- Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
- Marked anxiety, tension, and/or feelings of being keyed up or on edge.
Emotion and Physiology
Autonomic nervous system controls physiological arousal
Sympathetic division (arousing): dilates pupils, decreases salivation, creates perspiration, accelerates heart, inhibits digestion, secretes stress hormones
Parasympathetic division (calming): contracts pupils, increases salivation, dries skin, decreases respiration, slows heart, activates digestion, decreases secretion of stress hormones
Panic Loop
- Body Sensations: an unusual bodily sensation (e.g. pounding heart) makes you react with fear that something bad is about to happen
- Panic Attack: your continued overreaction to the bodily sensation triggers more fear and eventually leads to a full panic attack
- High Anxiety: once the panic attack subsides, you are left feeling anxious in a very sensitive state
- Fear of Fear: Your fear of having another panic attack keeps your anxiety levels high and this leads to further unusual bodily sensations. The panic loop is now established.
Trichotillomania Disorder (5)
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological
condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder
(e. g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic
disorder) .
Hoarding Disorder DSM-IV Changes
Hoarding used to be diagnosed under OCD, OCPD, and Anxiety NOS but now it is its own disorder
Body Dysmorphic Disorder - Culture and Gender Considerations
Taijin Kyofusho
- Shubo-kyofu (fear of body deformity)
- Jikoshu-kyofu (fear of having offensive body odor)
Males: muscle dysmorphia and genital preoccupations
Females: comorbid eating disorders
Premenstrual Dysphoric Disorder - Onset and Course
Onset at any time
Symptoms peak in intensity around the time of menses onset
Premenstrual phase is a risk period for suicide
Symptoms seem to worsen approaching menopause, but cease thereafter
Hormone replacement can re-trigger symptoms
Use of oral contraceptives help
MDD - Differential Diagnosis - Sadness
periods of sadness are inherent aspects of the human experience. These periods should not be diagnosed as a major depressive episode unless criteria are met for severity (i.e., five out of nine symptoms), duration (i.e., most of the day, nearly every day for at least 2 weeks), and clinically significant distress or impairment.
The diagnosis other specified depressive disorder may be appropriate for presentations of depressed mood wiih clinically significant impairment that do not meet criteria for duration or severity.
Agoraphobia Etiology, Risk and Prognostic Factors
Genetics/physiological
- family history
- heritability = 61%
Temperament
-Negative affectivity, anxiety sensitivity
Environment
- Stressful life events
- Reduced family warmth and overprotectiveness
MDD Recovery
Recurrence is common
- 2 episodes = 70% recurrence
- 3 episodes = 90%
recurrence 20% recover within 3 months of onset
80% recover within 1 year
Selective Mutism Criteria (5)
A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) 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 (not limited to the first month of school).
D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
E. The disturbance is not better explained by a communication disorder (e.g., childhood-onset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
Social Anxiety Disorder Criteria (10)
A. 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 interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if: performance only
Separation Anxiety Disorder Prevalence, Development, and Course
Most prevalent among children younger than 12
- Children 4%
- Adolescents 1.6%
- Adults .09% - 1.9%
Separation Anxiety is part of normal early development
Onset as early as preschool age, commonly during childhood, and rarely in adolescence and beyond
Majority of children grow out of it
Anxiety is manifested differently depending on age
HPA Axis
OCD Feedback Loop
Prefrontal Cortex to Striatum (Caudate Nucleus - Brain Filter) to Thalamus (Brain Router) back to PFC
People w OCD have increased activity in PFC
