Midterm (DSM) Flashcards
Bipolar - Etiology
Diathesis-Stress Model
Heritability is high: 60-85%
- 10-25% chance of having bipolar if one parent has it
- Shared genetic origin with schizophrenia
MRI studies
- Prefrontal cortex smaller and functions less well
- Reduced grey matter
- Demyelination in white matter
Hallucinations
a false sensory perception that occurs in the absence of an external sensory stimulus
involuntary, appear real
auditory or visual hallucinations are most common
a person must be awake and fully alert to experience a hallucination
-hypnaogic or hynopompic (waht we see or hear when we’re falling asleep) are normal and are not hallucinations
Autism Spectrum Disorder - Specifiers
With or without accompanying inteliectual impairment
With or without accompanying language impairment
-without language was aspergers
Associated with a icnown medicai or genetic condition or environmental factor
-Used to be Retts and CDD
Associated with another neurodevelopmental, mental, or behavioral disorder
With catatonia
Autism Spectrum Disorder - Differential Diagnosis - Stereotypic movement disorder
Motor stereotypies are among the diagnostic characteristics
of autism spectrum disorder, so an additional diagnosis of stereotypic movement
disorder is not given when such repetitive behaviors are better explained by the presence
of autism spectrum disorder. However, when stereotypies cause self-injury and become a
focus of treatment, both diagnoses may be appropriate.
ADHD - Differential Diagnosis - Other Neurodevelopmental Disorders
The increased motoric activity that may occur in
ADHD must be distinguished from the repetitive motor behavior that characterizes stereotypic
movement disorder and some cases of autism spectrum disorder. In stereotypic
movement disorder, the motoric behavior is generally fixed and repetitive (e.g., body rocking,
self-biting), whereas the fidgetiness and restlessness in ADHD are typically generalized
and not characterized by repetitive stereotypic movements. In Tourette’s disorder,
frequent multiple tics can be mistaken for the generalized fidgetiness of ADHD. Prolonged
observation may be needed to differentiate fidgetiness from bouts of multiple tics.
Persistent (Chronic) Motor or Vocal Tic Disorder Criteria
A. Single or multiple motor or vocal tics have been present during the illness, but not both
motor and vocal.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since
first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine)
or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder.
Specify
- with motor tics only
- with vocal tics only
Delusions
A strongly held false belief that remains unchanged, despite evidence to the contrary
Several types
- Persecutory
- Referential
- Grandiose
- Erotomanic
- Jealous
- Nihilistic
- Somatic
- Thought control
- Passivity
Bizarre (non-possible) or nonbizarre (improbable but possible)
Major Depressive Epidsode - Criteria
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, or 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 another
medical condition.
Note: Criteria A-C constitute a major depressive episode. Major depressive episodes are
common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
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.
Schizophrenia - Differential Diagnosis - Schizophreniform Disorder and Brief Psychotic Disorder
These disorders are of shorter
duration than schizophrenia as specified in Criterion C, which requires 6 months of symptoms.
In schizophreniform disorder, the disturbance is present less than 6 months, and in
brief psychotic disorder, symptoms are present at least 1 day but less than 1 month.
Intellectual Disability - Differential Diagnosis - Communication Disorders and Specific Learning Disorder
These neurodevelopmental disorders are specific to the communication and learning domains and do not show deficits in intellectual and adaptive behavior. They may co-occur with intellectual disability. Both diagnoses are made if full criteria are met for intellectual disability and a communication disorder or specific learning disorder.
Syndrome
this term is applied to a constellation of symptoms that occur together or co-vary over time
Tic Disorders - Prevalence
3 per 1000 in school-age children
Meta-analysis of 35 studies
.77% tourette’s
2.99% “Transient Tic Disorder”
.05% among adults
2:1 to 4:1 male to female ratio
Tends to be lower in African American and Hispanic populations
ADHD - Course
Continues through adolescence and often adulthood
Typically hyperactivity decreases (brain maturation)
Higher risk for ODD, CD, and Substance Use Disorder
Functional Outcomes:
Power school/work performance Lower academic/work atainment Unemployment Social rejection Accidents and injuries Fmaily conflict
ADHD - Differential Diagnosis - Neurocognitive Disorders
Early major neurocognitive disorder (dementia) and/or
mild neurocognitive disorder are not known to be associated with ADHD but may present
with similar clinical features. These conditions are distinguished from ADHD by their late
onset.
Tic Disorders - Differential Diagnosis - Abnormal Movements that may accompany other medical conditiosn and stereotypic movement disorder
Motor stereotypies are defined as involuntary rhythmic, repetitive,
predictable movements that appear purposeful but serve no obvious adaptive function or
purpose and stop with distraction. Examples include repetitive hand waving/rotating,
arm flapping, and finger wiggling. Motor stereotypies can be differentiated from tics based
on the former’s earlier age at onset (younger than 3 years), prolonged duration (seconds to
minutes), constant repetitive fixed form and location, exacerbation when engrossed in activities,
lack of a premonitory urge, and cessation with distraction (e.g., name called or
touched). Chorea represents rapid, random, continual, abrupt, irregular, unpredictable,
nonstereotyped actions that are usually bilateral and affect all parts of the body (i.e., face,
trunk, and limbs). The timing, direction, and distribution of movements vary from moment
to moment, and movements usually worsen during attempted voluntary action. Dystonia
is the simultaneous sustained contracture of both agonist and antagonist muscles,
resulting in a distorted posture or movement of parts of the body. Dystonie postures are often
triggered by attempts at voluntary movements and are not seen during sleep.
Stererotypic Movement Disorder - Differential Diagnosis - Other neurological and medical conditions
The diagnosis of stereotypic movements
requires the exclusion of habits, mannerisms, paroxysmal dyskinesias, and benign hereditary
chorea. A neurological history and examination are required to assess features
suggestive of other disorders, such as myoclonus, dystonia, tics, and chorea. Involuntary
movements associated with a neurological condition may be distinguished by their signs
and symptoms. For example, repetitive, stereotypic movements in tardive dyskinesia can
be distinguished by a history of chronic neuroleptic use and characteristic oral or facial
dyskinesia or irregular trunk or limb movements. These types of movements do not result
in self-injury. A diagnosis of stereotypic movement disorder is not appropriate for repetitive
skin picking or scratching associated with amphetamine intoxication or abuse (e.g.,
patients are diagnosed with substance/medication-induced obsessive-compulsive and related
disorder) and repetitive choreoathetoid movements associated with other neurological
disorders.
Specific Learning Disorder - Differential Diagnosis - Learning Difficulties Due to Neurological or Sensory Disorders
Specific learning disorder
is distinguished from learning difficulties due to neurological or sensory disorders
(e.g., pediatric stroke, traumatic brain injury, hearing impairment, vision impairment), because
in these cases there are abnormal findings on neurological examination.
What makes bipolar hard to diagnose?
People come in for the depression, not the manias, may not see mania as a problem
High rates of comorbidity
Shared psychotic features
Difficulty disentangling timelines from substance use
So many variations in how it presents in the room/how people experience the disorder
ADHD - Differential Diagnosis - Specific Learning Disorder
Children with specific learning disorder may appear inattentive
because of frustration, lack of interest, or limited ability. However, inattention in
individuals with a specific learning disorder who do not have ADHD is not impairing outside
of academic work.
Schizophrenia - Differential Diagnosis - Postraumatic Stress Disorder
Posttraumatic stress disorder may include flashbacks that
have a hallucinatory quality, and hypervigilance may reach paranoid proportions. But a traumatic
event and characteristic symptom features relating to reliving or reacting to the event
are required to make the diagnosis.
Schizoaffective Disorder - Prevalence and Course
Lifetime Prevalence = .3%
More common among females, especially depressive type
Typical age of onset – early adulthood
- Bioplar type more common amongst young adults
- Depressive type more common among older adults
Prognosis slightly better than schizophrenia, but worse than mood disorders
-often associated with impaired functioning, although not part of criterion
Intellectual Disability - Differential Diagnosis - Autism Spectrum Disorder
ID is common among individuals with autism spectrum disorder. Assessment of intellectual ability may be complicated by social- communication and behavior deficits inherent to autism spectrum disorder, which may interfere with understanding and complying with test procedures. Appropriate assessment of intellectual functioning in autism spectrum disorder is essential, with reassessment across the developmental period, because IQ scores in autism spectrum disorder may be unstable, particularly in early childhood.
Bipolar - Prevalence
1.8% - 4.4% of US population (lifeactime) across BDI, BDII, and BDNOS
12-month prevalence rate
BDI = 0.6%
BDII = 0.8%
Nearly equal in men and women
Rapid cycling, mixed states, and depressive episodes more often in women
Schizophreniform Disorder - Criteria
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),
or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. An episode of the disorder lasts at least 1 month but less than 6 months. When the
diagnosis must be made without waiting for recovery, it should be qualified as “provisional.”
‘
C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have
been ruled out because either 1 ) no major depressive or manic episodes have occurred
concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during
active-phase symptoms, they have been present for a minority of the total duration
of the active and residual periods of the illness.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
Note: impairment in social and occupational functioning is not required
Specific Learning Disorder - Etiology
Genetic X Environment
- runs in families
- prematurity
- low birth weight
- prenatal exposure to toxins
Complex Motor tic examples
Combo of motor tics
Echopraxia (repeating a movement they have seen)
Coprapraxia (doing obsene things)
Schizoaffective Disorder
Specify whether:
Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.
Depressive type: This subtype applies if only major depressive episodes are part of the presentation.
Specify if:
With catatonia
Specify if:
The following course specifiers are only to be used after a 1 -year duration of the disorder
and if they are not in contradiction to the diagnostic course criteria.
First episode, currently in acute episode: First manifestation of the disorder meeting
the defining diagnostic symptom and time criteria. An acute episode is a time period
in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a time period during
which an improvement after a previous episode is maintained and in which the defining
criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be determined
after a minimum of two episodes (i.e., after a first episode, a remission and a
minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods being
very brief relative to the overall course.
Unspecified
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior,
and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe).
Note: Diagnosis of schizoaffective disorder can be made without using this severity
specifier.
Tic Disorders - Development and Course
Onset typically between ages 4-6
Peak severity typically between ages 10-12, after which severity declines
Tics may wax/wane or change
Comorbidity depends on age
- childhood: ADHD, OCD, separation anxiety
- Teens/Adults: MDD, SUD, or Bipolar Disorder
Many with mild symptoms experience little to no impairment
Autism Spectrum Disorder - Differential Diagnosis - Schizophrenia
Schizophrenia with childhood onset usually develops after a period of
normal, or near normal, development. A prodromal state has been described in which social
impairment and atypical interests and beliefs occur, which could be confused with the
social deficits seen in autism spectrum disorder. Hallucinations and delusions, which are
defining features of schizophrenia, are not features of autism spectrum disorder. However,
clinicians must take into account the potential for individuals with autism spectrum
disorder to be concrete in their interpretation of questions regarding the key features of
schizophrenia (e.g., “Do you hear voices when no one is there?” “Yes [on the radio]”).
Intellectual Disability Course
Lifelong, but serverity may change
Improved functioning with early and ongoing interventions
-Reassess infants and young children post-intervention
Many live full lives
ADHD - Differential Diagnosis - Medication Induced Symptoms of ADHD
Symptoms of inattention, hyperactivity, or
impulsivity attributable to the use of medication (e.g., bronchodilators, isoniazid, neuroleptics
[resulting in akathisia], thyroid replacement medication) are diagnosed as other
specified or unspecified other (or unknown) substance-related disorders.
Steps to determining a diagnosis
- Consider GMC or Physical causes
- Consider Substance-Induced or Related Disorder
- Consider Cultural and Developmental Factors
- Determine Diagnoses
- Resolve Diagnostic Uncertainty
- Consider Comorbidity and Assocaited Features
- Assess Level of Distress and/or Impairment
ADHD - Differential Diagnosis - Depressive Disorders
Individuals with depressive disorders may present with inability
to concentrate. However, poor concentration in mood disorders becomes prominent
only during a depressive episode.
Symptom
refers to an observable behavior or state
Developmental Coordination Disorder - Differential Diagnosis
Motor impairments due to another medical condition
ID
ADHD
ASD
Joint hypermobility syndrome
Intellectual Disability - Differential Diagnosis
A diagnosis of intellectual disability should not be assumed because of a particular genetic or medical condition. A genetic syndrome linked to intellectual disability should be noted as a concurrent diagnosis with the intellectual disability.
Major and Mild Neurocognitive Disorders
Communication Disorders and Specific Learning Disorders
Autism Spectrum Disorder
Schizophrenia Specifiers
The following course specifiers are only to be used after a 1-year duration of the disorder
and if they are not in contradiction to the diagnostic course criteria.
First episode, currently in acute episode: First manifestation of the disorder meeting
the defining diagnostic symptom and time criteria. An acute episode is a time period
in which the symptom criteria are fulfilled.
First episode, currently in partial remission: Partial remission is a period of time
during which an improvement after a previous episode is maintained and in which the
defining criteria of the disorder are only partially fulfilled.
First episode, currently in full remission: Full remission is a period of time after a
previous episode during which no disorder-specific symptoms are present.
Multiple episodes, currently in acute episode: Multiple episodes may be determined
after a minimum of two episodes (i.e., after a first episode, a remission and a
minimum of one relapse).
Multiple episodes, currently in partial remission
Multiple episodes, currently in full remission
Continuous: Symptoms fulfilling the diagnostic symptom criteria of the disorder are
remaining for the majority of the illness course, with subthreshold symptom periods being
very brief relative to the overall course.
Unspecified
Specify if:
With catatonia
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior,
and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe).
Bipolar with atypical features
This specifier can be applied when these features predominate
during the majority of days of the current or most recent major depressive episode.
A. Mood reactivity (i.e., mood brightens in response to actual or potential positive
events).
B. Two (or more) of the following features:
1. Significant weight gain or increase in appetite.
2. Hypersomnia.
3. Leaden paralysis (i.e., heavy, leaden feelings in arms or legs).
4. A long-standing pattern of interpersonal rejection sensitivity (not limited to episodes
of mood disturbance) that results in significant social or occupational
impairment.
C. Criteria are not met for “with melancholic features” or “with catatonia” during the
same episode.
Specific Learning Disorder - Cultural Considerations
Occurs across cultures but may manifest differently
-e.g. alphabetic languages vs. non-alphabetic languages
Consider language proficiency in diagnosis
Childhood Onset Fluency Disorder - Differential Diagnosis - Adult-onset dysfluencies
If onset of dysfluencies is during or after adolescence, it is an
“adult-onset dysfluency” rather than a neurodevelopmental disorder. Adult-onset dysfluencies
are associated with specific neurological insults and a variety of medical conditions
and mental disorders and may be specified with them, but they are not a DSM-5 diagnosis
What does appropriate diagnosis involve?
Identifying the individual’s clinical presentation, characteristic signs, and symptoms
Matching these to psychiatric diagnostic categories
Comprehensive understanding of disorders, diagnostic assessment, ability to idenitfy diagnostic clues, signs and symptoms, common core symptoms and features that allow for differentiation between daignoses
Specific Learning Disorder - Differential Diagnosis - ID
Specific learning disorder
differs from general learning difficulties associated with intellectual disability, because the
learning difficulties occur in the presence of normal levels of intellectual functioning (i.e.,
IQ score of at least 70 ± 5). If intellectual disability is present, specific learning disorder can
be diagnosed only when the learning difficulties are in excess of those usually associated
with the intellectual disability.
Specific Learning Disorder - Differential Diagnosis - Normal Variations in Academic Attaintment
Specific learning disorder is distinguished
from normal variations in academic attainment due to external factors (e.g., lack of educational
opportunity, consistently poor instruction, learning in a second language), because
the learning difficulties persist in the presence of adequate educational opportunity
and exposure to the same instruction as the peer group, and competency in the language of
instruction, even when it is different from one’s primary spoken language.
Bipolar I - Differential Diagnosis - Other Bipolar Disorders
Diagnosis of bipolar I disorder is differentiated from bipolar II
disorder by determining whether there have been any past episodes of mania. Other specified
and unspecified bipolar and related disorders should be differentiated from bipolar I
and II disorders by considering whether either the episodes involving manic or hypomanic
symptoms or the episodes of depressive symptoms fail to meet the full criteria for
those conditions.
Bipolar disorder due to another medical condition may be distinguished from bipolar
I and II disorders by identifying, based on best clinical evidence, a causally related medical
condition.
Tic Disorders - Etiology and Risk Factors
Genetic X Environment
- heritability in families
- older parental age
- brith complications
- low birth weight
- prenatal exposure to toxins (e.g. smoking)
Worsened by anxiety, stress, exhaustions, and excitement
Specific Learning Disorder - Diagnosis
Clinical Interview
Education/Psychological Assessment
-look at specific subscores to be 1.5 SD below average
School reports
Parent/Other reports
Curriculum-based measures
Portfolio of work
Need to incorporate medical, developmental, educational and family hx
Language Disorder - Comorbidity
Language disorder is strongly associated with other neurodevelopmental disorders in
terms of specific learning disorder (literacy and numeracy), attention-deficit/hyperactivity
disorder, autism spectrum disorder, and developmental coordination disorder. It is
also associated with social (pragmatic) communication disorder. A positive family history
of speech or language disorders is often present.
ADHD Considerations
Inattention is hard to detect
Hyperacgtivity can be mistaken for disciplinary problems
Typically diagnosed in elementary school
- normal child behavior is hyperactive
- kids may not be required to sit still before that
Symptoms may vary across settings and age
Beware of over-diagnosis
Schizophrenia - Differential Diagnosis - Schizotypal Personality Disorder
Schizotypal personality disorder may be distinguished
from schizophrenia by subthreshold symptoms that are associated with persistent personality
features.
Why is diagnosis important?
Define Clinical Entities
- serves as a short-hand notation for a syndrome or cluster of symptoms that commonly occur together
- Communication
Determine Treatment
- Prerequisite fro appropriate treatment
- Allows for identification of appropriate interventions and prediction of treatment response and outcome
ADHD - Specifiers
Combined presentation
Predominantly inattentive presentation
Predominantly hyperactive/impulsive presentation
Specify if:
in partial remission: When full criteria were previously met, fewer than the full criteria
have been met for the past 6 months, and the symptoms still result in impairment in
social, academic, or occupational functioning.
Specify current severity:
Mild - Few, if any, symptoms in excess of those required to make the diagnosis are
present, and symptoms result in no more than minor impairments in social or occupational
functioning.
Moderate - Symptoms or functional impairment between “mild” and “severe” are present.
Severe - Many symptoms in excess of those required to make the diagnosis, or several
symptoms that are particularly severe, are present, or the symptoms result in marked
impairment in social or occupational functioning
Schizophrenia prevalence & risk factors
.3-.7% lifetime prevalence ~1% in literature
slightly fewer females
males have earlier onset than females
- males early-mid 20s
- females late 20s
Variation by race/ethnicity, across countries
Genetics X Environmental
- heritability, risk alleles idenitifed
- approx 10% of first degree relaitves of patients with schizophrenia develop the condition
prenatla/perinatal factors
Specific Learning Disorder - Differential Diagnosis - Neurocognitive Disorders
Specific learning disorder is distinguished from learning
problems associated with neurodegenerative cognitive disorders, because in specific
learning disorder the clinical expression of specific learning difficulties occurs during the
developmental period, and the difficulties do not manifest as a marked decline from a former
state.
Specific Learning Disorder - Specifiers
Specify all academic domains and subskills that are impaired
- Reading
- Writing
- Math
Severity
Mild, Moderate, Severe (based on number of domains and how much support they need)
Global Developmental Delay
This diagnosis is reserved for individuals under the age of 5 years when the clinical severity
level cannot be reliably assessed during early childhood. This category is diagnosed when
an individual fails to meet expected developmental milestones in several areas of intellectual
functioning, and applies to individuals who are unable to undergo systematic assessments
of intellectual functioning, including children who are too young to participate in
standardized testing.
This category requires reassessment after a period of time (not a permanent diagnosis)
Catatonia
A. The clinical picture is dominated by three (or more) of the following symptoms:
- Stupor (i.e., no psychomotor activity; not actively relating to environment).
- Catalepsy (i.e., passive induction of a posture held against gravity).
- Waxy flexibility (i.e., slight, even resistance to positioning by examiner).
- Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]).
- Negativism (i.e., opposition or no response to instructions or external stimuli).
- Posturing (i.e., spontaneous and active maintenance of a posture against gravity).
- Mannerism (i.e., odd, circumstantial caricature of normal actions).
- Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements).
- Agitation, not influenced by external stimuli.
- Grimacing.
- Echolalia (i.e., mimicking another’s speech).
- Echopraxia (i.e., mimicking another’s movements).
Childhood Onset Fluency Disorder - Prevalance
3:1 Male to Female
If speech doesn’t improve by age 8 you could see it persist into teenage years
ADHD - Etiology
Genetics
Abnormal/delayed brain maturation (multiple genes developing normally but delayed in growth)
-Specific brain areas include basal ganglia (emotional regulation) and cerebellum (timing, motor control)
Environmental factors
- prentalue eposure to alcohol/drugs
- exposure to toxins (e.g. lead)
- TBI
Brain waves are dif in child with ADHD
Schizoaffective Disorder - Differential Diagnosis - Schizophrenia, Bipolar, and Depressive Disorders
Distinguishing schizoaffective disorder
from schizophrenia and from depressive and bipolar disorders with psychotic features
is often difficult. Criterion C is designed to separate schizoaffective disorder from
schizophrenia, and Criterion B is designed to distinguish schizoaffective disorder from a
depressive or bipolar disorder with psychotic features. More specifically, schizoaffective
disorder can be distinguished from a depressive or bipolar disorder with psychotic features
based on the presence of prominent delusions and/or hallucinations for at least 2 weeks in
the absence of a major mood episode. In contrast, in depressive or bipolar disorder with
psychotic features, the psychotic features primarily occur during the mood episode(s). Because
the relative proportion of mood to psychotic symptoms may change over time, the
appropriate diagnosis may change from and to schizoaffective disorder. (For example, a
diagnosis of schizoaffective disorder for a severe and prominent major depressive episode
lasting 3 months during the first 6 months of a chronic psychotic illness would be changed
to schizophrenia if active psychotic or prominent residual symptoms persist over several
years without a recurrence of another mood episode.)
Autism Spectrum Disorder - Prevalence and Development
1% of population
4:1 male to female
Late, underdiagnosis in African American children (lack of access to healthcare?)
Typically recognize symptoms between 1-2 years of age
Higher rates in recent years
What is a tic?
Sudden, rapid, recurrent, nonrhythmic motor movement or vocalization
-usually occur in head and face
Symptoms may change over time
Can be simple or complex
- simple: last a couple seconds
- complex: can be combo of simple, last longer
Usually preceded by an urge
Typically experienced as “involuntary” although can be resisted
Schizophreniform - Differential Diagnosis - Other mental disorders and medical conditions
A wide variety of mental and medical
conditions can manifest with psychotic symptoms that must be considered in the differential
diagnosis of schizophreniform disorder. These include psychotic disorder due to
another medical condition or its treatment; delirium or major neurocognitive disorder;
substance/medication-induced psychotic disorder or delirium; depressive or bipolar
disorder with psychotic features; schizoaffective disorder; other specified or unspecified bipolar
and related disorder; depressive or bipolar disorder with catatonic features; schizophrenia;
brief psychotic disorder; delusional disorder; other specified or unspecified schizophrenia
spectrum and other psychotic disorder; schizotypal, schizoid, or paranoid
personality disorders; autism spectrum disorder; disorders presenting in childhood with
disorganized speech; attention-deficit/hyperactivity disorder; obsessive-compulsive disorder;
posttraumatic stress disorder; and traumatic brain injury.
Since the diagnostic criteria for schizophreniform disorder and schizophrenia differ
primarily in duration of illness, the discussion of the differential diagnosis of schizophrenia
also applies to schizophreniform disorder.
Autism Spectrum Disorder - Core Features
Impairment in Social Communication and Interaction
- Deficits in social-emotional reciprocity
- Deficits in nonverbal communicative behaviors
- Deficits in developing, maintaining and understanding relationships
Restricted, Repetitive Patterns of Behavior, Interests, and Activites (at least 2)
- Stereotyped/repetitive motor movements or speech
- Insistence on sameness, rigid routines
- Ex: handflapping, rocking, repeating one word a lot
- High restricted, fixated interests abnormal in intensity
- Hyper/hypo-sensitivity to sensory input
- Could also be tactile
Developmental Coordination Disorder - Etiology
genetics, especially severe cases
possible cerebellar dysfunction
Environmental factors
- low birth weight
- prematurity
- prenatal alcohol exposure
Stereotypic Movement Disorder Criteria
A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand
shaking or waving, body rocking, head banging, self-biting, hitting own body).
-often rhythmic
B. The repetitive motor behavior interferes with social, academic, or other activities and
may result in self-injury.
C. Onset is in the early developmental period.
-children will often move in repetitive patterns, but can stop if they are told to. Children will also go through phases of doing certain movements normally
D. The repetitive motor behavior is not attributable to the physiological effects of a substance
or neurological condition and is not better explained by another neurodevelopmental
or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessivecompulsive
disorder).
ADHD - Differential Diagnosis - Substance Use Disorder
Differentiating ADHD from substance use disorders may be
problematic if the first presentation of ADHD symptoms follows the onset of abuse or frequent
use. Clear evidence of ADHD before substance misuse from informants or previous
records may be essential for differential diagnosis.
Schizophrenia - Differential Diagnosis - Schizoaffective Disorder
A diagnosis of schizoaffective disorder requires that a major
depressive or manic episode occur concurrently with the active-phase symptoms and that
the mood symptoms be present for a majority of the total duration of the active periods.
Criticism of the DSM-5
Poor reliablity and validity
Focus on symptoms rather than what causes the symptoms
Problems distinguishing normal from abnormal
Cultural Bias
Distinct categories vs. dimensions
Tendency to overpathologize
Specific Learning Disorder - Differential Diagnosis - Psychotic Disorders
Specific learning disorder is distinguished from the academic and
cognitive-processing difficulties associated with schizophrenia or psychosis, because with
these disorders there is a decline (often rapid) in these functional domains.
Bipolar - Comorbidities
approx 75% have comorbid disorders
Prognosis is worse when comorbid
Specific Learning Disorder - Impairment in Written Expression
Writing skills are below expected for age
Difficulty with:
- Grammar
- Punctuation
- Spelling
- Clearly articulating ideas in writing
Not due to poor coordination or penmenship (more related to act of writing (motor skills)
Hypomania - Criteria
A. 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.
B. During the period of mood disturbance and increased energy and activity, three (or
more) of the following symptoms (four if the mood is only irritable) have persisted, represent
a noticeable change from usual behavior, and have been present to a significant
degree:
*DIGFAST
- Distractibility
- Indiscretion/Recklessness. Excessive involvement in activities that have a high potential for painful consequences
(e. g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). - Grandiosity or inflated self-esteem
- Flight of ideas or subjective experience that thoughts are racing.
- Activity increase, goal-directed (either socially, at work or school, or sexually) or psychomotor agitation (i.e., puposeless non-goal-directed activity).
- Sleep loss; decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic
of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning or to necessitate hospitalization. If there are psychotic features, the
episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, other treatment).
Note: A full hypomanic episode that emerges during antidepressant treatment (e.g.,
medication, electroconvulsive therapy) but persists at a fully syndromal level beyond
the physiological effect of that treatment is sufficient evidence for a hypomanic episode
diagnosis. However, caution is indicated so that one or two symptoms (particularly increased
irritability, edginess, or agitation following antidepressant use) are not taken
as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar
diathesis.
Note: Criteria A-‘F constitute a hypomanic episode. Hypomanic episodes are common in
bipolar I disorder but are not required for the diagnosis of bipolar I disorder.
Social (Pragmatic) Communication Disorder - Differential Diagnosis - Intellectual Disability and Global Developmental Delay
Social communication skills may be deficient among individuals with global developmental
delay or intellectual disability, but a separate diagnosis is not given unless
the social communication deficits are clearly in excess of the intellectual limitations.
WHODAS
World Health Organization Disability Assessment Scale
Replaced GAF from DSM IV
Used to determine disability
Language Disorder - Differential Diagnosis - Language Regression
Loss of speech and language in a child younger than 3 years may be a sign of autism spectrum disorder (with developmental regression) or a specific neurological
condition, such as Landau-Kleffner syndrome. Among children older than 3 years,
language loss may be a symptom of seizures, and a diagnostic assessment is necessary to
exclude the presence of epilepsy (e.g., routine and sleep electroencephalogram).
Stereotypic Movement Disorder - Specifiers
With/without self-injurious behaviors
Associated with a known medical or genetic condition, neurodevelopmental disorder, or enviornmental factor (specify condition)
Severity
mild, moderate, severe
Bipolar - Risk/Prognostic Factors
More common in high income countries
Marriage, education ,and fewer years of ilness predict better prognosis
Presence of psychotic features predicts more psychosis
Mood-incongruent psychotic features predict less complete recovery periods
Functional recovery lags behind symptom recovery
-30% severe work impairment –> lower SES
Cognitive impairment
High suicide risk: 15x greater than general population
- 32-36% attempt suicide
- Lethality appears to be higher for those with Bipolar II
Specific Learning Disorder - Impairment in Math
Math skills are below expected for age
Difficulty with:
- counting
- understanding math concepts and symbols
- learning and performing simple math operations (e.g. adding or subtracting)
- Math reasoning (e.g. applying concepts to solve problems – word problems)
Childhood-Onset Fluency Disorder (Stuttering)
A. Disturbances in the normal fluency and time patterning of speech that are inappropriate
for the individual’s age and language skills, persist over time, and are characterized
by frequent and marked occurrences of one (or more) of the following:
1. Sound and syllable repetitions.
2. Sound prolongations of consonants as well as vowels.
3. Broken words (e.g., pauses within a word).
4. Audible or silent blocking (filled or unfilled pauses in speech).
5. Circumlocutions (word substitutions to avoid problematic words).
6. Words produced with an excess of physical tension.
7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).
B. The disturbance causes anxiety about speaking or limitations in effective communication,
social participation, or academic or occupational performance, individually or in
any combination.
C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases
are diagnosed as 307.0 [F98.5] adult-onset fluency disorder.)
D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency associated
with neurological insult (e.g., stroke, tumor, trauma), or another medical condition
and is not better explained by another mental disorder.
Autism Spectrum Disorder - Differential Diagnosis - ADHD
Abnormalities of attention (overly focused or
easily distracted) are common in individuals with autism spectrum disorder, as is hyperactivity.
A diagnosis of attention-deficit/hyperactivity disorder (ADHD) should be
considered when attentional difficulties or hyperactivity exceeds that typically seen in individuals
of comparable mental age.
Psychosis
out of touch with reality
defined by 5 symptoms:
- hallucinations
- delusions
- disorganized thinking (speech)
- disoragnized behavior
- negative symptoms
Autism Spectrum Disorder - Differential Diagnosis - Selective Mutism
In selective mutism, early development is not typically disturbed.
The affected child usually exhibits appropriate communication skills in certain contexts
and settings. Even in settings where the child is mute, social reciprocity is not impaired,
nor are restricted or repetitive patterns of behavior present.
Developmental Coordination Disorder Criteria
A. The acquisition and execution of coordinated motor skills is substantially below that expected
given the individual’s chronological age and opportunity for skill learning and
use. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects)
as well as slowness and inaccuracy of performance of motor skills (e.g., catching an
object, using scissors or cutlery, handwriting, riding a bike, or participating in sports).
B. The motor skills deficit in Criterion A significantly and persistently interferes with activities
of daily living appropriate to chronological age (e.g., self-care and self-maintenance)
and impacts academic/school productivity, prevocational and vocational
activities, leisure, and play.
C. Onset of symptoms is in the early developmental period.
-typically not diagnosed before age 5
D. The motor skills deficits are not better explained by intellectual disability (Intellectual developmental disorder) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder).
Social (Pragmatic) Communication Disorder - Differential Diagnosis - Autism Spectrum Disorder
Autism spectrum disorder is the primary diagnostic consideration
for individuals presenting with social communication deficits. The two disorders
can be differentiated by the presence in autism spectrum disorder of restricted/
repetitive patterns of behavior, interests, or activities and their absence in social (pragmatic)
communication disorder. Individuals with autism spectrum disorder may only display
the restricted/repetitive patterns of behavior, interests, and activities during the early
developmental period, so a comprehensive history should be obtained. Current absence of
symptoms would not preclude a diagnosis of autism spectrum disorder, if the restricted
interests and repetitive behaviors were present in the past. A diagnosis of social (pragmatic)
communication disorder should be considered only if the developmental history
fails to reveal any evidence of restricted/repetitive patterns of behavior, interests, or activities
Schizophrenia - Differential Diagnosis - Other Mental Disorders Associated with a Psychotic Episode
The diagnosis of schizophrenia
is made only when the psychotic episode is persistent and not attributable to the
physiological effects of a substance or another medical condition. Individuals with a delirium
or major or minor neurocognitive disorder may present with psychotic symptoms,
but these would have a temporal relationship to the onset of cognitive changes consistent
with those disorders. Individuals with substance/medication-induced psychotic disorder
may present with symptoms characteristic of Criterion A for schizophrenia, but the substance/
medication-induced psychotic disorder can usually be distinguished by the chronological
relationship of substance use to the onset and remission of the psychosis in the
absence of substance use.
Stereotypic Movement Disorder - Etiology
Cause is unknown
Associated risk & prognostic factors
- lower cognitive functioning
- may be behavioral sign of neurogenetic syndrome
- medical conditions
- stress/fear
- social isolation
Intellectual Disability
Intellectual disability (intellectual developmental disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three criteria must be met:
A. Deficits in intellectual functions, such as reasoning, problem-solving, planning, abstract
thinking, judgment, academic learning, and learning from experience, confirmed by
both clinical assessment and individualized, standardized intelligence testing.
-IQ of 70 or lower (>2 SD below mean +/- 5 for error) generally but need to look at adaptive functioning deficits
B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural
standards for personal independence and social responsibility. Without ongoing
support, the adaptive deficits limit functioning in one or more activities of daily life,
such as communication, social participation, and independent living, across multiple
environments, such as home, school, work, and community.
- 3 Domains: conceptual, social, and practical
- Impairment present in at least one but often it is all three
C. Onset of intellectual and adaptive deficits during the developmental period.
Childhood Onset Fluency Disorder - DIfferential Diagnosis - Sensory Deficits
Dysfluencies of speech may be associated with a hearing impairment
or other sensory deficit or a speech-motor deficit. When the speech dysfluencies are in excess
of those usually associated with these problems, a diagnosis of childhood-onset fluency
disorder may be made.
Autism Spectrum Disorder - Course
Symptoms most marked in early childhood
Typically not degenerative
Majority need some support in adulthood
Comorbid with anxiety, depression, ADHD, oCD, ID, SLD
Prognosis linked to impairements in language and intellect and other mental health problems
-the more problems the worse off they will be later on
Stererotypic Movement Disorder - Differential Diagnosis - Normal Development
Simple stereotypic movements are common in infancy and early
childhood. Rocking may occur in the transition from sleep to awake, a behavior that usually
resolves with age. Complex stereotypies are less common in typically developing
children and can usually be suppressed by distraction or sensory stimulation. The individual’s
daily routine is rarely affected, and the movements generally do not cause the
child distress. The diagnosis would not be appropriate in these circumstances.
Language Disorder - Differential Diagnosis
Normal variations in language
Hearing or other sensory impairment
Intellectual disability (intellectual developmental disorder)
Neurological disorders
Language regression
Comorbidity
Intellectual Disability Etiology
Prenatal
- Genetic
- Inbord errors of metabolism
- Brain malformations
- Maternal/placental disease
- Environmental influences
Perinatal (at or around time of birth)
- Prematurity
- Anoxia
- Birth trauma
Postnatal/acquired
- TBI
- Hypoxic ischemic injury
- Infections/illnesses
- Seizure disorders
- Toxins
- Severe/chronic social deprivation
Sometimes unexplained or no cause
Tic Disorders - Other specified/unspecified
When to use?
- Atypical in age of onset
- Atypical in presentation
- known etiology
ADHD General Criteria
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development, as characterized by (1) and/or (2):
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age
12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings
(e.g., at home, school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (e.g., mood
disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication
or withdrawal).
Substance/Medication-Induced Psychotic Disorder Critieria
A. Presence of one or both of the following symptoms:
- Delusions.
- Hallucinations.
B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
- The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication. - The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by a psychotic disorder that is not substance/
medication-induced. Such evidence of an independent psychotic disorder could include
the following:
The symptoms preceded 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 of an independent
non-substance/medication-induced psychotic disorder (e.g., a history of recurrent
non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Note: This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and when they are sufficiently severe to warrant clinical attention.
ADHD - Differential Diagnosis - Psychotic Disorders
ADHD is not diagnosed if the symptoms of inattention and hyperactivity
occur exclusively during the course of a psychotic disorder.
Developmental Coordination Disorder - Differential Diagnosis - ASD
Individuals with autism spectrum disorder may be uninterested
in participating in tasks requiring complex coordination skills, such as ball sports,
which will affect test performance and function but not reflect core motor competence. Cooccurrence
of developmental coordination disorder and autism spectrum disorder is common.
If criteria for both disorders are met, both diagnoses can be given.
ADHD - Associated Features
Language, motor, social delays
Cognitive problems (poor executive functioning, memory)
Academic/work impairement
Mood, conduct, and substance use disorders (higher in ADHD individuals)
Simple vocal tic examples
Throat clearing
sniffing
grunting
bark, squeak
Stererotypic Movement Disorder - Differential Diagnosis - ASD
Stereotypic movements may be a presenting symptom of
autism spectrum disorder and should be considered when repetitive movements and behaviors
are being evaluated. Deficits of social communication and reciprocity manifesting
in autism spectrum disorder are generally absent in stereotypic movement disorder, and
thus social interaction, social communication, and rigid repetitive behaviors and interests
are distinguishing features. When autism spectrum disorder is present, stereotypic movement
disorder is diagnosed only when there is self-injury or when the stereotypic behaviors
are sufficiently severe to become a focus of treatment.
Stereotypic Movement Disorder - Prevalence & Course
3-4% develop complex stereotypies
More common in boys than girls
Highly comorbid with ID
Typically onset in first 3 years of life
Usually resolves over time or can be suppressed in typically developing kids
Bipolar - Development
Average age of onset is late adolescence (BDI) to mid-20s (BDII)
Median onset prior to age 18
Prevalence is estimated at 1.8-2.5% in adolescnece
For BDII, onset often begins with depressive episode
Early onset associated with worse outcomes
> 90% with mania, go on to have recurring episodes
~60% of manic episodes are follwed by depressive episode
Aprox 6% of adults & 20-25% of adolescents with BDII progress to BDI
Bipolar - Brain
Neural Correlates
- Hyperactiviation of amygdala
- Decreased activity in hippocampus and anterior cingulate
- Hypoactivation in vIPFC
Neurotransmitters:
- Dopamine levels appear to be increased during mania and depleted during depression
- Levels of serotonin are diminished lead to depressive episodes
- Elevated glutamate levels
Intellectual Disability Prevalence
1% of general population
May be identifiable within first 2 years of life
More prevalent in males than females (3:2)
Speech Sound Disorder - Differential Diagnosis - Normal variations in speech
Regional, social, or cultural/ethnic variations of speech
should be considered before making the diagnosis.
Autism Spectrum Disorder - Criteria
A. Persistent deficits in social communication and social interaction across multiple contexts,
as manifested by the following, currently or by history (examples are illustrative,
not exhaustive; see text):
1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social
approach and failure of normal back-and-forth conversation; to reduced sharing of
interests, emotions, or affect; to failure to initiate or respond to social interactions.
2. Deficits in nonverbal communicative behaviors used for social interaction, ranging,
for example, from poorly integrated verbal and nonverbal communication; to abnormalities
in eye contact and body language or deficits in understanding and use of
gestures: to a total lack of facial expressions and nonverbal communication.
3. Deficits in developing, maintaining, and understanding relationships, ranging, for example,
from difficulties adjusting behavior to suit various social contexts; to difficulties
in sharing imaginative play or in making friends; to absence of interest in peers.
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive
patterns of behavior (seeTable 2).
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at
least two of the following, currently or by history (examples are illustrative, not exhaustive;
see text):
1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple
motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic
phrases).
2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of
verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties
with transitions, rigid thinking patterns, greeting rituals, need to take same route or
eat same food every day).
3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g.,
strong attachment to or preoccupation with unusual objects, excessively circumscribed
or perseverative interests).
4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of
the environment (e.g., apparent indifference to pain/temperature, adverse response
to specific sounds or textures, excessive smelling or touching of objects,
visual fascination with lights or movement).
Specify current severity:
Severity is based on social communication impairments and restricted, repetitive
patterns of behavior (see Table 2).
C. Symptoms must be present in the early developmental period (but may not become
fully manifest until social demands exceed limited capacities, or may be masked by
learned strategies in later life).
D. Symptoms cause clinically significant impairment in social, occupational, or other important
areas of current functioning.
E. These disturbances are not better explained by intellectual disability (intellectual developmental
disorder) or global developmental delay. Intellectual disability and autism
spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected
for general developmental level.
Note: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s
disorder, or pervasive developmental disorder not otherwise specified should be given the
diagnosis of autism spectrum disorder. Individuals who have marked deficits in social
communication, but whose symptoms do not otherwise meet criteria for autism spectrum
disorder, should be evaluated for social (pragmatic) communication disorder.
Speech Sound Disorder - Differential Diagnosis
Normal variations in speech
Hearing or other sensory impairment
Structural deficits
Dysarthria
Selective mutism
Psychotic Disorder Due to Another Medical Condition
A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Childhood Schizophrenia
very rare
visual hallucinations are more common
more prominent negative symptoms
poorer outcomes
Stererotypic Movement Disorder - Differential Diagnosis - Tic disorders
Typically, stereotypies have an earlier age at onset (before 3 years) than
do tics, which have a mean age at onset of 5-7 years. They are consistent and fixed in their
pattern or topography compared with tics, which are variable in their presentation. Stereotypies
may involve arms, hands, or the entire body, while tics commonly involve eyes,
face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged in duration
than tics, which, generally, are brief, rapid, random, and fluctuating. Tics and stereotypic
movements are both reduced by distraction.
Language Disorder - Differential Diagnosis - Normal Variations in Language
Language disorder needs to be distinguished from normal
developmental variations, and this distinction may be difficult to make before 4 years
of age. Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be
considered when an individual is being assessed for language impairment.
Brief Psychotic Disorder - Prevalence, course, risk
Accounts for 9% of first-onset psychosis
Onset can ocur across lifespan, avergae age in mid-30s
More common in females
Predisposition for those with certain personality disorders
Full remission – better functional outcomes
Schizophrenia - Brain
Decreased brain volume
- Reduced gray matter
- Less white matter connectivity
- white matter transfers information from cell to cell
- Reduction increases with age
reducation especially prevelant in frontal lobe and temporal lobe
enlarged ventricles
neurotransmitters
- evelated dopamine and noradrenaline (noraepinephrine)
- decreased GABA and glutamate
ADHD - Differential Diagnosis - Personality Disorders
In adolescents and adults, it may be difficult to distinguish ADHD
from borderline, narcissistic, and other personality disorders. All these disorders tend to
share the features of disorganization, social intrusiveness, emotional dysregulation, and
cognitive dysregulation. However, ADHD is not characterized by fear of abandonment,
self-injury, extreme ambivalence, or other features of personality disorder. It may take
extended clinical observation, informant interview, or detailed history to distinguish impulsive,
socially intrusive, or inappropriate behavior from narcissistic, aggressive, or domineering
behavior to make this differential diagnosis.
Specific Learning Disorder - Differential Diagnosis - ADHD
Specific learning disorder is distinguished from
the poor academic performance associated with ADHD, because in the latter condition the
problems may not necessarily reflect specific difficulties in learning academic skills but
rather may reflect difficulties in performing those skills. However, the co-occurrence of
specific learning disorder and ADHD is more frequent than expected by chance. If criteria
for both disorders are met, both diagnoses can be given.
Autism Spectrum Disorder - Differential Diagnosis - Language Disoders and Social (Pragamtic) Communication Disorder
In some forms
of language disorder, there may be problems of communication and some secondary social
difficulties. However, specific language disorder is not usually associated with abnormal
nonverbal communication, nor with the presence of restricted, repetitive patterns of
behavior, interests, or activities.
When an individual shows impairment in social communication and social interactions
but does not show restricted and repetitive behavior or interests, criteria for social (pragmatic)
communication disorder, instead of autism spectrum disorder, may be met. The diagnosis
of autism spectrum disorder supersedes that of social (pragmatic) communication
disorder whenever the criteria for autism spectrum disorder are met, and care should be
taken to enquire carefully regarding past or current restricted/repetitive behavior.
Speech Sound Disorder - Differential Diagnosis - Hearing or Other Sensory Impairment
Hearing impairment or deafness may result in
abnormalities of speech. Deficits of speech sound production may be associated with a
hearing impairment, other sensory deficit, or a speech-motor deficit. When speech deficits
are in excess of those usually associated with these problems, a diagnosis of speech sound
disorder may be made.
Speech Sound Disorder - Differential Diagnosis - Dysarthria
Speech impairment may be attributable to a motor disorder, such as cerebral
palsy. Neurological signs, as well as distinctive features of voice, differentiate dysarthria
from speech sound disorder, although in young children (under 3 years) differentiation
may be difficult, particularly when there is no or minimal general body motor involvement
(as in, e.g., Worster-Drought syndrome).
Schizoaffective Disorder Criteria
A. An uninterrupted period of illness during which there is a major mood episode (major
depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1 : Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode
(depressive or manic) during the lifetime duration of the illness.
-helps you seperate from mood disorders with psychotic features
C. Symptoms that meet criteria for a major mood episode are present for the majority of
the total duration of the active and residual portions of the illness.
-many people switch between SA and Schizophrenia because of this “majority” rule
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition.
Intellectual Disability Etiology
Prenatal
- Genetic
- Inbord errors of metabolism
- Brain malformations
- Maternal/placental disease
- Environmental influences
Perinatal (at or around time of birth)
- Prematurity
- Anoxia
- Birth trauma
Postnatal/acquired
- TBI
- Hypoxic ischemic injury
- Infections/illnesses
- Seizure disorders
- Toxins
- Severe/chronic social deprivation
Sometimes unexplained or no cause
Autism Spectrum Disorder - Differential Diagnosis
Rett Syndrome
Selective Mutism
Language Disorders and social (pragmatic) communication disorder
Intellectual Disability wihtout autism spectrum disorder
Stereotypic movement disorder
ADHD
Schizophrenia
Brief Psychotic Disorder - Specifiers
Specify if:
With marked stressor(s) (brief reactive psychosis): If symptoms occur in response to
events that, singly or together, would be markedly stressful to almost anyone in similar
circumstances in the individual’s culture.
Without marited stressor(s): If symptoms do not occur in response to events that,
singly or together, would be markedly stressful to almost anyone in similar circumstances
in the individual’s culture.
With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum.
Specify if:
With catatonia
Severity
Schizoaffective Disorder - Differential Diagnosis - Psychotic Disorder Due to Another Medical Condition
Other medical conditions and
substance use can manifest with a combination of psychotic and mood symptoms, and
thus psychotic disorder due to another medical condition needs to be excluded.
Cyclothymic Disorder - Criteria
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), the hypomanic
and depressive periods 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 hypomaniec episode have never been met.
D. The symptoms in Criterion A are not better explained by schizoaffective disorder,
schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified
schizophrenia spectrum and other psychotic disorder.
E. The symptoms are not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
Specify if:
With anxious distress (see p. 149)
Disorganized Behavior
Physical actions that don’t appear goal-directed
Strange/bizarre behavior
Inappropriate affect
Catatonia
ADHD Hyperactivity/Impulsivity
Six (or more) of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with developmental level
and that negatively impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves
his or her place in the classroom, in the office or other workplace, or in other
situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents
or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable
being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes
people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or
activities; may start using other people’s things without asking or receiving permission;
for adolescents and adults, may intrude into or take over what others
are doing).
Language Disorder Criteria
A. Persistent difficulties in the acquisition and use of language across modalities (i.e.,spoken, written, sign language, or other) due to deficits in comprehension or production that include the following:
- Reduced vocabulary (word knowledge and use).
- Limited sentence structure (ability to put words and word endings together to form
sentences based on the rules of grammar and morphology). - Impairments in discourse (ability to use vocabulary and connect sentences to explain
or describe a topic or series of events or have a conversation).
B. Language abilities are substantially and quantifiably below those expected for age, resulting
in functional limitations in effective communication, social participation, academic
achievement, or occupational performance, individually or in any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to hearing or other sensory impairment, motor dysfunction,
or another medical or neurological condition and are not better explained by intellectual
disability (intellectual developmental disorder) or global developmental delay.
Bipolar II - Specifiers
Specify current or most recent episode:
Hypomanic
Depressed
Specify if:
With anxious distress (p. 149)
With mixed features (pp. 149-150)
With rapid cycling (pp. 150-151)
Withi mood-congruent psychotic features (p. 152)
With mood-incongruent psychotic features (p. 152)
With catatonia (p. 152).
With péripartum onset (pp. 152-153)
With seasonal pattern (pp. 153-154): Applies only to the pattern of major depressive episodes.
Specify course if full criteria for a mood episode are not currently met:
in partial remission (p. 154)
In full remission (p. 154)
Specify severity if full criteria for a mood episode are currently met:
Mild (p. 154)
Moderate (p. 154)
Severe (p.154)
Specific Learning Disorder - Course
Lifelong, persisting into adulthood
- May manifest differently with age
- May result in poorer life outcomes
Variable in course
- Severity
- Environment/Task demands
- Learning ability
- Comorbidity
- Available Support
Schizophrenia Criteria
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), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning
in one or more major areas, such as work, interpersonal relations, or self-care, is
markedly below the level achieved prior to the onset (or when the onset is in childhood
or adolescence, there is failure to achieve expected level of interpersonal, academic,
or occupational functioning).
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) and may include periods of prodromal or residual
symptoms. During these prodromal or residual periods, the signs of the disturbance may
be manifested by only negative symptoms or by two or more symptoms listed in Criterion
A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features
have been ruled out because either 1 ) no major depressive or manic episodes have
occurred concurrently with the active-phase symptoms, or 2) if mood episodes have
occurred during active-phase symptoms, they have been present for a minority of the
total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g., a
drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood
onset, the additional diagnosis of schizophrenia is made only if prominent delusions
or hallucinations, in addition to the other required symptoms of schizophrenia,
are also present for at least 1 month (or less if successfully treated).
Manic Episode - Criteria
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or energy, lasting at
least 1 week and present most of the day, nearly every day (or any duration if hospitalization
is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a significant
degree and represent a noticeable change from usual behavior:
*DIGFAST
- Distractibility
- Indiscretion/Recklessness. Excessive involvement in activities that have a high potential for painful consequences
(e. g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). - Grandiosity or inflated self-esteem
- Flight of ideas or subjective experience that thoughts are racing.
- Activity increase, goal-directed (either socially, at work or school, or sexually) or psychomotor agitation (i.e., puposeless non-goal-directed activity).
- Sleep loss; decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
C. The mood disturbance is sufficiently severe to cause marked impairment in social or
occupational functioning or to necessitate hospitalization to prevent harm to self or others,
or there are psychotic features.
D. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, other treatment) or to another medical condition.
Note: A full manic episode that emerges during antidepressant treatment (e.g., medication,
electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a manic episode and,
therefore, a bipolar I diagnosis.
Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is required
for the diagnosis of bipolar I disorder.
Shizophrenia - Considerations
Culture
- what beliefs are considered delusional
- part of one’s religious experiences?
- differences in emotional expression? langauge barriers?
Gender
- females have later onset, more psychotic and mood symptoms, which may worsen later in life
- less negative sympoms and disorganization
Negative Symptoms
Affect - Flat or blunted affect
Alogia - Reduced speech and fluency
Avolition - Loss of motivation or the will to do things
Anhedonia - Reduced experience of pleasure
Asociality - Lack of interest in social interactions
Bipolar I - Specifiers
With anxious distress (p. 149) With mixed features (pp. 149-150) With rapid cycling (pp. 150-151) With melancholic features (p. 151) With atypical features (pp. 151-152) With mood-congruent psychotic features (p. 152) With mood-incongruent psychotic features (p. 152) With catatonia (p. 152). With peripartum onset (pp. 152-153) With seasonal pattern (pp. 153-154)
Language Disorder - Differential Diagnosis - Intellectual Disability
Language delay is often the
presenting feature of intellectual disability, and the definitive diagnosis may not be made
until the child is able to complete standardized assessments. A separate diagnosis is not
given unless the language deficits are clearly in excess of the intellectual limitations
ADHD - Differential Diagnosis - Bipolar Disorder
Individuals with bipolar disorder may have increased activity, poor
concentration, and increased impulsivity, but these features are episodic, occurring several
days at a time. In bipolar disorder, increased impulsivity or inattention is accompanied
by elevated mood, grandiosity, and other specific bipolar features. Children with
ADHD may show significant changes in mood within the same day; such lability is distinct
from a manic episode, which must last 4 or more days to be a clinical indicator of bipolar
disorder, even in children. Bipolar disorder is rare in preadolescents, even when
severe irritability and anger are prominent, whereas ADHD is common among children
and adolescents who display excessive anger and irritability.
Pediatric Bipolar
Controversial
How do we know it exists?
Retrospective studies
- Most adult bipolar patients report an onset prior to age 21 (as early as 13)
- Associated with worse outcome
Prospective
- Depression in adolescnece has high rates of conversion to BP (20-40%)
- 30% with BDNOS progress to I or II within 4 years
Tourette’s Disorder Criteria
A. Both multiple motor and one or more vocal tics have been present at some time during
the illness, although not necessarily concurrently.
B. The tics may wax and wane in frequency but have persisted for more than 1 year since
first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine)
or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
Developmental Coordination Disorder - Differential Diagnosis - Joint Hypermobility Syndrome
Individuals with syndromes causing hyperextensible
joints (found on physical examination; often with a complaint of pain) may present with
symptoms similar to those of developmental coordination disorder
Speech Sound Disorder Criteria
A. Persistent difficulty with speech sound production that interferes with speech intelligibility
or prevents verbal communication of messages.
B. The disturbance causes limitations in effective communication that interfere with social
participation, academic achievement, or occupational performance, individually or in
any combination.
C. Onset of symptoms is in the early developmental period.
D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral
palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medical
or neurological conditions.
Different from langauge disorder because child can produce language in their head but have a hard time expressing languge
Social (Pragmatic) Communication Disorder - Etiology and Course
High heritability, likely family hx
Onset in early childhood, but problems not clearly distinguishable or stable until around age 4
Motor Disorders (List)
Developmental Coordination Disorder
Stereotypic Movement Disorder
Tic Disorders
Other Specified Tic Disorder
Unspecified Tic Disorder
Speech Sound Disorder - Differential Diagnosis - Structural Deficits
Speech impairment may be due to structural deficits (e.g., cleft palate).
Disorganized Speech
Tangential or loose associations
Circumstantial (so much detail you lose the train of thought)
“Word Salad” - Unintelligible, incoherent speech
Impairs effective communication
Representative of impaired or disorganized thinking
Disease
- a disorder where the underlying etiology is known
- it is the highest level of conceptual understanding
Developmental Coordination Disorder - Differential Diagnosis - ID
If intellectual disability is
present, motor competences may be impaired in accordance with the intellectual disability.
However, if the motor difficulties are in excess of what could be accounted for by the
intellectual disability, and criteria for developmental coordination disorder are met, developmental
coordination disorder can be diagnosed as well.
Schizophreniform - Specifiers
Specify if:
With good prognostic features: This specifier requires the presence of at least two
of the following features:
- onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning
- confusion or perplexity
- good premorbid social and occupational functioning
- absence of blunted or flat affect.
Without good prognostic features: This specifier is applied if two or more of the
above features have not been present.
Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition).
Specify current severity:
Severity is rated by a quantitative assessment of the primary symptoms of psychosis,
including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior,
and negative symptoms. Each of these symptoms may be rated for its current
severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present)
to 4 (present and severe). (See Clinician-Rated Dimensions of Psychosis Symptom
Severity in the chapter “Assessment Measures.”)
Note: Diagnosis of schizophreniform disorder can be made without using this severity
specifier.
Specific Learning Disorder - Impairment in Reading
Cannot read at the expected age level
Dyslexia is one type
Difficulty with:
- Speed of reading (reading fluency)
- Accuracy of reading (e.g. decoding)
- Comprehension
Complex vocal tic examples
combo of vocal tics
echolalia (repetition of something heard)
Copralalia (says profane things)
Palilalia (repeating ones own words)
Childhood Onset Fluency Disorder - Differential Diagnosis - Normal Speech Dysfluencies
The disorder must be distinguished from normal dysfluencies
that occur frequently in young children, which include whole-word or phrase repetitions
(e.g., ‘T want, I want ice cream”), incomplete phrases, interjections, unfilled
pauses, and parenthetical remarks. If these difficulties increase in frequency or complexity
as the child grows older, a diagnosis of childhood-onset fluency disorder is appropriate.
Developmental Coordination Disorder - Pevalence and Associated Features
Prevalence 5-6% amongth children ages 5-11
Male to female ranges from 2:1 to 7:1
Associated feature
- “overflow” movements
- Choreiform movements
- Mirror movements
Delusional Disorder - Criteria
The presence of one (or more) delusions with a duration of 1 month 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 (e.g., the sensation of being infested with insects associated with delusions of
infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly
impaired, and behavior 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 or another
medical condition and is not better explained by another mental disorder, such
as body dysmorphic disorder or obsessive-compulsive disorder.
Simple motor tic examples
eye blinking
head jerk
shoulder shrug
facial grimace
Bipolar I - Criteria
A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode”
above).
B. The occurrence of the manic and major depressive episode(s) is not better explained
by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder,
or other specified or unspecified schizophrenia spectrum and other psychotic
disorder.
Disorder
- like a syndrome, refers to a cluster of symptoms
- implies there is a disruption of normal functions in the body
ADHD - Differential Diagnosis - ID
Symptoms of ADHD are
common among children placed in academic settings that are inappropriate to their intellectual
ability. In such cases, the symptoms are not evident during non-academic tasks. A
diagnosis of ADHD in intellectual disability requires that inattention or hyperactivity be
excessive for mental age.
Brief Psychotic Disorder Criteria
A. Presence of one (or more) of the following symptoms. At least one of these must be
(1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
Note: Do not include a symptom if it is a culturally sanctioned response.
B. 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.
C. The disturbance is not better explained by major depressive or bipolar disorder with
psychotic features or another psychotic disorder such as schizophrenia or catatonia,
and is not attributable to the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition
Speech Disorder - Age
Most speech sounds should be produced clearly by age 7
Late eight (l, r, s, z, th, ch, dzh, and zh) after age 8
Shizophrenia - Development and Course
Onset stypically between late teens to early 30s
- earlier onset predicts worse prognosis
- worse inital psychotic episode, more likely they are to relapse (biggest predictor)
Prodromal period - abnormalities of thought, language, perception, and motor behavior
Gradual worsening of illness
Psychotic event
Causes impairment – impaired cognition is common and can persist
Chronic and lifelong: few recover to their premorbid state
30-40% of patients on therapeutic doses of antipsychotic medications continue to experience symptoms
Negative symptoms more persistent and predict worse prognosis
Developmental Coordination Disorder - Course
50-70% of children continue to have problems w/ movement and coordination through teens
Functional outcomes:
- Reduced participation in sports
- Obesity and poorer physical fitness
- poor self-esteem
- emotional/behavior problems
- impaired academic achievement
ADHD Inattention Criteria
Inattention: Six (or more) of the following symptoms have persisted for at least
6 months to a degree that is inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.
a. Often fails to give close attention to details or makes careless mistakes in
schoolwork, at work, or during other activities (e.g., overlooks or misses details,
work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty
remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere,
even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and
is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential
tasks; difficulty keeping materials and belongings in order; messy, disorganized
work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils,
books, tools, wallets, keys, papenwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and
adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older
adolescents and adults, returning calls, paying bills, keeping appointments).
Stages of Schizophrenia
3 stages
- at least 6 months for the whole cycle
- hard to pin point where prodrom begins and ends which makes it harder to track time
Prodromal
- usually 1-2 years ahead of active stage
- symptoms vague, easy to miss
- two types: initial prodrom and relapse prodrom
Active
- presence of positive and negative symptoms
- at least one month
Residual
-presently no strong positive symptoms, may have mild symptoms, or negative symptoms
Bipolar II - Critieria
A. Criteria have been met for at least one hypomanie episode (Criteria A-F under “Hypomanic
Episode” above) and at least one major depressive episode (Criteria A-C under
“Major Depressive Episode” above).
B. There has never been a manic episode.
C. The occurrence of the hypomanie episode(s) and major depressive episode(s) is not
better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified or unspecified schizophrenia spectrum and
other psychotic disorder.
D. The symptoms of depression or the unpredictability caused by frequent alternation between
periods of depression and hypomania causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning
Schizophrenia - Differential Diagnosis - Delusional Disorder
Delusional disorder can be distinguished from schizophrenia by
the absence of the other symptoms characteristic of schizophrenia (e.g., delusions, prominent
auditory or visual hallucinations, disorganized speech, grossly disorganized or catatonic
behavior, negative symptoms).
Other Specified Bipolar and Related Disorder
Short duration hypomanic episodes
Insufficient symptoms for hypomanic episodes
Hypomanic episode w/o depression
Short duration cyclothymia
Shizophrenia - Functional Outcomes
Men are less likely to marry
Social isolation
Often need supported living
Difficult to sustain employement
-avolition, cognitive impairments, relapse of symptoms
More medical problems
- poor self-care
- weight gain, diabetes, metabolic syndrome, cardiovascular and pumonary diseases
Reduced life expectancy
20% attempt suicide, 10% complete
Provisional Tic Disorder - Criteria
A. Single or multiple motor and/or vocal tics.
B. The tics have been present for less than 1 year since first tic onset.
C. Onset is before age 18 years.
D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine)
or another medical condition (e.g., Huntington’s disease, postviral encephalitis).
E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or
vocal tic disorder
Delusional Disorder - Prevalence and course
.2% lifetime prevalence (approx.03% in literature)
No gender differences
-Jealous type more common in females
Most frequent subtype is persecutory
Generally stable, but a few go on to develop schizophrenia
ADHD - Differential Diagnosis - ASD
Individuals with ADHD and those with autism spectrum
disorder exhibit inattention, social dysfunction, and difficult-to-manage behavior. The social
dysfunction and peer rejection seen in individuals with ADHD must be distinguished
from the social disengagement, isolation, and indifference to facial and tonal communication
cues seen in individuals with autism spectrum disorder. Children with autism spectrum
disorder may display tantrums because of an inability to tolerate a change from their
expected course of events. In contrast, children with ADHD may misbehave or have a tantrum
during a major transition because of impulsivity or poor self-control.
Specific Learning Disorder - Differential Diagnosis
Normal variations in academic attainment
ID
Learning difficulties due to neurological or sensory disorders
Neurocognitive disorders
ADHD
Psychotic disorders
Schizophreniform - Prevalence and Course
In the US 5x less common than schizophrenia
1/3 Recover and 2/3 go on to meet criteria for schizophrenia or schizoaffective
people that truly have schizophreniform recover
Specific Learning Disorder - Prevalence & Manifestation
5-15% among school-age children
Estimated 4% among adults
-people learn to cope and end up pursuing something that plays to their strengths rather than their weaknesses
More common in males (2-3:1)
Frequently preceded by attention, language, and motor delays
Uneven profiles are common
-Avg IQ, doing generally well but specifically bad at math, for example
May include behavioral manifestations
Bipolar I - Differential Diagnosis - ADHD
This disorder may be misdiagnosed as bipolar
disorder, especially in adolescents and children. Many symptoms overlap with the symptoms
of mania, such as rapid speech, racing thoughts, distractibihty, and less need for
sleep. The “double counting” of symptoms toward both ADHD and bipolar disorder can
be avoided if the clinician clarifies whether the symptom(s) represents a distinct episode.
Speech Sound Disorder - Key Features
May be due to poor knowledge of speech sounds or trouble coordinating movements to make the sounds
Substituting one sound for another or omitting certain sounds, or speaking with a lisp
- wabbit
- gaspetti
- cotco
Diagnosis must consider child’s age and development
-Age 2, gibberish speech is common
By late teens, prevalance = 1 in 200
Social (Pragmatic) Communication Disorder - Differential Diagnosis - ADHD
Primary deficits of ADHD may cause impairments
in social communication and functional limitations of effective communication, social
participation, or academic achievement.
Autism Spectrum Disorder - Differential Diagnosis - ID without ASD
Intellectual disability without autism spectrum disorder may be difficult to
differentiate from autism spectrum disorder in very young children. Individuals with intellectual
disability who have not developed language or symbolic skills also present a
challenge for differential diagnosis, since repetitive behavior often occurs in such individuals
as well. A diagnosis of autism spectrum disorder in an individual with intellectual
disability is appropriate when social communication and interaction are significantly impaired
relative to the developmental level of the individual’s nonverbal skills (e.g., fine
motor skills, nonverbal problem solving). In contrast, intellectual disability is the appropriate
diagnosis when there is no apparent discrepancy between the level of social-communicative
skills and other intellectual skills.
Developmental Coordination Disorder - Differential Diagnosis - ADHD
Individuals with ADHD may fall, bump into
objects, or knock things over. Careful observation across different contexts is required to
ascertain if lack of motor competence is attributable to distractibility and impulsiveness
rather than to developmental coordination disorder. If criteria for both ADHD and developmental
coordination disorder are met, both diagnoses can be given.
Specific Learning Disorder - Criteria
A. Difficulties learning and using academic skills, as indicated by the presence of at least
one of the following symptoms that have persisted for at least 6 months, despite the
provision of interventions that target those difficulties:
1. Inaccurate or slow and effortful word reading (e.g., reads single words aloud incorrectly
or slowly and hesitantly, frequently guesses words, has difficulty sounding
out words).
2. Difficulty understanding the meaning of what is read (e.g., may read text accurately
but not understand the sequence, relationships, inferences, or deeper meanings of
what is read).
3. Difficulties with spelling (e.g., may add, omit, or substitute vowels or consonants).
4. Difficulties with written expression (e.g., makes multiple grammatical or punctuation
errors within sentences; employs poor paragraph organization; written expression
of ideas lacks clarity).
5. Difficulties mastering number sense, number facts, or calculation (e.g., has poor
understanding of numbers, their magnitude, and relationships; counts on fingers to
add single-digit numbers instead of recalling the math fact as peers do; gets lost in
the midst of arithmetic computation and may switch procedures).
6. Difficulties with mathematical reasoning (e.g., has severe difficulty applying mathematical
concepts, facts, or procedures to solve quantitative problems).
-academic skills that are acquired or learned (not like IQ)
B. The affected academic skills are substantially and quantifiably below those expected
for the individual’s chronological age, and cause significant interference with academic
or occupational performance, or with activities of daily living, as confirmed by individually
administered standardized achievement measures and comprehensive clinical
assessment. For individuals age 17 years and older, a documented history of impairing
learning difficulties may be substituted for the standardized assessment.
C. The learning difficulties begin during school-age years but may not become fully manifest
until the demands for those affected academic sl
Language Disorder - Differential Diagnosis - Hearing or Other Sensory Impairment
Hearing impairment needs to be excluded as the
primary cause of language difficulties. Language deficits may be associated with a hearing
impairment, other sensory deficit, or a speech-motor deficit. When language deficits are in
excess of those usually associated with these problems, a diagnosis of language disorder
may be made.
ADHD - Differential Diagnosis - Disruptive Mood Dysregulation Disorder
Disruptive mood dysregulation disorder is
characterized by pervasive irritability, and intolerance of frustration, but impulsiveness
and disorganized attenhon are not essential features. However, most children and adolescents
with the disorder have symptoms that also meet criteria for ADHD, which is diagnosed
separately.
Intellectual Disability - Differential Diagnosis - Major and Mild Neurocognitive Disorders
Intellectual disability is categorized as a neurodevelopmental
disorder and is distinct from the neurocognitive disorders, which are
characterized by a loss of cognitive functioning. Major neurocognitive disorder may cooccur
with intellectual disability (e.g., an individual with Down syndrome who develops
Alzheimer’s disease, or an individual with intellectual disability who loses further cognitive
capacity following a head injury). In such cases, the diagnoses of intellectual disability
and neurocognitive disorder may both be given.
ADHD - Differential Diagnosis
Oppositional defiant disorder
Intermittent explosive disorder
Other neurodevelopmental disorders
Specific Learning Disorder
ID
ASD
Reactive attachment disorder
Anxiety disorders
Depressive disorders
Bipolar disorder
Disruptive mood dysregulation disorder
Substance use disoders
Personality Disorders
Psychotic disorders
Medication-induced symptoms of ADHD
Neurocognitive disorders
