NEURODEVELOPMENTAL DISORDERS
Deficits in using communication in social purposes
- group of conditions with onset in the developmental period, typically
manifest early in development
INTELLECTUAL DISABILITIES
1) Intellectual Disability (Intellectual Developmental
Disorder)
- DSM-IV-TR: Mental Retardation
a. It is characterized by deficits in general mental abilities, such as
reasoning, problem solving, planning, abstract thinking, judgment,
academic learning, and learning from experience.
b. Deficits result in impairments of adaptive functioning, such that the
individual fails to meet standards of personal independence and social
responsibility in one or more aspects of daily life.
c. onset is during the developmental period
Specifiers:
- The various levels of severity are defined on the basis of adaptive
functioning, and not IQ scores, because it is adaptive functioning that
determines the level of supports required.
Prevalence: 1% and vary by age
- Males are more likely than females to be diagnosed with both mild
and severe forms of intellectual disability.
Other Classifications
2) Global Developmental Delay
- Is diagnosed when individual fails to meet expected developmental
milestones in several areas of intellectual functioning.
- 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 also applies to individual who are unable to undergo systematic
assessment of intellectual functioning.
- requires reassessment after a period of time
3) Unspecified Intellectual Disability
- This category is reserved for individuals over the age of 5 years when
assessment of the degree of intellectual disability by means of locally
available procedures is rendered difficult or impossible because of
associated sensory or physical impairments.
COMMUNICATION DISORDERS
- include deficits in language, speech, and communication
1) Language Disorder
a. persistent difficulties in the acquisition and use of language across
modalities:
1. reduced vocabulary
2. limited sentence structure
3. Impairments in discourse
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 (both expressive & receptive)
c. onset of symptoms in the developmental period
d. The difficulties are not attributable to hearing or other sensory
impairment and are not better explained by intellectual disability or
global developmental delay.
- By age 4, individual differences in language ability are more stable,
with better measurement accuracy, and are highly predictive of later
outcomes.
2) Speech Sound Disorder
- includes phonological disorder and articulation disorder (impairment
in the ability coordinate the movements of tongue, jaw, and lips)
- also termed as verbal dyspraxia
a. persistent difficulty with speech and sound production that interferes
with speech intelligence or prevents verbal communication of
messages.
b. The disturbance causes limitation in effective communications
c. onset of symptoms on developmental period
d. The difficulties are not attributable to congenital or acquired
conditions
3) 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
characterized by:
1. Sound and syllable repetitions
2. Sound prolongations of consonants and vowels
3. Broken words (pauses within a word)
4. Audible or silent blocking
5. Circumlocutions (word substitution to avoid problematic
words)
6. Words produced with an excess of physical tension
7. Monosyllabic whole-word repetitions
b. The disturbance causes anxiety about speaking or limitations in
effective communication, social participation, or academic or
occupational performance.
c. The onset of symptoms is the early developmental period (adult-
onset fluency disorder for later-onset cases)
d. The disturbance is not attributable to speech-motor or sensory deficit
or another medical condition or mental disorder.
- Stress and anxiety can exacerbate dysfluency.
4) Social (Pragmatic) Communication Disorder
- primary difficulty in pragmatics, or the social use of language and
communication
a. persistent difficulties in the social use of verbal and nonverbal
communication
1.
2. Impairment of the ability to change communication to
match context or the needs of the listener
3. Difficulties following rules for conversation and
storytelling
4. Difficulties understanding what are not explicitly stated
b. functional limitation in effective communication
c. onset of symptoms is in the early developmental period
d. not attributable to another medical condition or neurological
condition or to low abilities in the domains of word structure and
grammar; and are not better explained by autism spectrum disorder,
intellectual disability and global developmental delay.
- Autism spectrum disorder and social communication disorder can be
differentiated by the presence in ASD of restricted/repetitive patterns of
behaviors, interests, and activities and their absence in social
communication disorder.
- Symptoms overlap with social phobia. In social communication
disorder, the individual has never had effective social communication;
in social anxiety disorder, social communication skills developed
appropriately but are not utilized because of anxiety and distress.
- Social communication deficit must be clearly in excess of the
intellectual limitations to preclude a diagnosis of this disorder and not
intellectual; disability.
4) Unspecified Communication Disorder
- When the symptoms characteristics do not meet the full criteria for
communication disorders.
AUTISM SPECTRUM DISORDERS
- Encompasses the DSM-IV autistic disorders such as autism,
Asperger’s disorder, childhood disintegrative disorders, and pervasive
developmental disorders not otherwise specified
- In DSM IV-TR, under the diagnoses usually first made in infancy,
childhood, or adolescence
a. persistent deficits in social communication and social interaction
across multiple contexts
1. Social-emotional reciprocity
2. Deficits in non-verbal communicative behaviors
3. Deficits in developing, maintaining, and understanding
relationships.
b. Restricted, repetitive patterns of behaviors, interests, or activities, as
manifested by at least two of the following:
1. Stereotyped or repetitive motor movements
2. Insistence on sameness, inflexible adherence to routines,
or ritualized patterns of behaviors
3. Highly restricted, fixated interests that are abnormal in
intensity
4. Hyper- or hypo-reactivity to sensory input or unusual
interest in sensory aspects the environment.
c. Symptoms must be present in the early developmental period.
d. significant impairment in social, occupational or other areas
e. not accounted by intellectual disability or global developmental delay
- Severity is based on social communication impairments and
restricted, repetitive patterns of behavior
Level 1: Requiring support
Level 2: Requiring substantial support
Level 3: Requiring very substantial support
Specify if:
- With or without accompanying developmental disorder
- With or without accompanying language impairment
- Associated with known medical or genetic condition or environmental
factor
- Associated with another neurodevelopmental, mental, or behavioral
disorder
- Symptoms are typically recognized during the second year of life (12-
24 months of age).
- Four times more often diagnosed in males than females. Females
tend to be more likely to show accompanying intellectual disability.
ATTENTION-DEFICIT/HYPERACTIVITYDISORDER
a. A persistent pattern of inattention and hyperactivity/impulsivity that
interferes with daily functioning
1. Inattention: six or more manifestations of persistent pattern of
inattention and hyperactivity-impulsivity for at least 6 months
(Note: Not solely a manifestation of oppositional behavior, defiance,
hostility or failure to understand tasks or instructions. For adolescents
and adults (17 and older) at least 5 symptoms are required
1. Failure to give close attention to details
2. Difficulty sustaining attention in tasks
3. Does not seem to listen when spoken to directly
4. Often does not follow through on instructions and fails to
finish works and duties
5.Difficulty organizing tasks and activities
6. Avoids tasks that require sustained mental effort
7. Often loses things necessary for tasks or activities
8. Easily distracted by extraneous stimuli
9. Often forgetful in daily activities
2. Hyperactivity and Impulsivity: 6 or more of the following
symptoms for at least 6 months
1. Fidgets with or taps hand or feet or squirms in seat
2. Often leaves in seat, when remaining seated is required
3. Runs about or climbs in situations where it is
inappropriate
4. Unable to play or engage in leisure activities quietly
5. Often “on the go” and restless
6. Often talks excessively
7. Often blurs out an answer before a question has been
completed
8. Often has difficulty waiting his turn
9. Often interrupts or intrudes on others
b. Symptoms were present prior to age 12 years (7 years old in IV)
c. Symptoms must be present in two or more settings
d. Symptoms interfere with, or reduce the quality of, social academic,
or occupational functioning
e. Symptoms do not occur exclusively during the course of
schizophrenia or another psychotic disorders and not better accounted
by another mental disorder
Specify if:
-Combined presentation
- Predominantly inattentive presentation
- Predominantly hyperactive/impulsive presentation
in partial remission: When the criteria were previously met, fewer
than the full criteria have been met for the past 6 months, and the
symptoms still result in impairment.
- mild, moderate, and severe
Other Specified ADHD: do not meet the full criteria for ADHD or any
of the disorders in the neurodevelopmental disorders diagnostic class
Unspecified ADHD: used in situations in which the clinician chooses
not to specify the reason that the criteria are not met, and in which
there is insufficient information to make a specific diagnosis.
SPECIFIC LEARNING DISORDER
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 interventions.
1. Inaccurate or slow and effortful word reading
2. Difficulty understanding the meaning of what is read
3. Difficulties with spelling
4. Difficulties with written expression
5.Difficulties mastering number sense, number facts, or
calculation
6. Difficulties with mathematical reasoning
b. The affected academic skills are substantially and quantifiably below
those expected for the individual’s chronological age, causing
significant interference (confirmed by standardized achievement
measures and comprehensive clinical assessment).
c. The learning difficulties begin during school-age years but may not
become fully manifest until the demands of those academic skills
exceed the individual’s limited capacities.
d. Not better accounted by intellectual disabilities, uncorrected visual or
auditory acuity, other mental or neurological disorders, psychosocial
adversity, lack of proficiency in the language of academic instruction,
or inadequate educational instruction.
Specify if:
- With impairment in reading (dyslexia)
word reading accuracy
reading rate or fluency
reading comprehension
- With impairment in written expression
spelling accuracy
grammar and punctuation accuracy
clarity or organization of written expression
- With impairment in mathematics (dyscalculia)
- number sense
- memorization of arithmetic facts
- accurate or fluent calculation
- accurate math reasoning
- if mild, moderate, or severe
- In children, it is indicated by school reports and teacher’s grades or
ratings. In adults, it is indicated by self-reports by others
- 1.0-2.5 SD below the population mean for age
- The defining character of specific learning disorder is “unexpected
academic achievement” and not part of a more general learning
difficulty (intellectual disability).
- more common in males
MOTOR DISORDERS
1) Developmental Coordination Disorder
a. The acquisition and execution of coordinated motor skills is
substantially below the expected given the individual’s chronological
age and opportunity for skill learning and use. Difficulties are
manifested as clumsiness and slowness and inaccuracy of
performance of motor skills
b. The motor skills deficit interferes with activities of daily living
appropriate to chronological age.
c. Onset of symptoms is in the early developmental period.
d. The motor skills deficits are not better explained by intellectual
disability, visual impairment, or neurological condition affecting
movement.
- also termed as childhood dyspraxia, specific developmental
disorder of motor function, and clumsy child syndrome
- Clinical synthesis of the history (developmental and medical),
physical examination, school or workplace report, and individual
assessment
- Typically not diagnosed before age 5 because there is a
considerable variation in the age acquisition of motor skills or lack of
stability of measurement in early childhood.
- Males are more affected than females.
- Proposed etiology: Cerebellar dysfunction, shared genetic effects
2) Stereotypic Movement Disorder
- Repetitive, seemingly driven, and apparently purposeless motor
behavior (e.g. hand shaking, body rocking, head banging).
- Age onset: before 3 years
Specify if:
- With or without self-injurious behavior
- Associated with a known medical or genetic condition,
neurodevelopmental disorder
- Mild, moderate, or severe
3) Tic Disorders
- A tic is a sudden, rapid, recurrent, nonrhytmic motor movement or
vocalization.
- Onset is before 18 years (Criterion C)
- The disturbance is not attributable to the physiological effects of a
substance or another medical condition
Tourette’s Disorder
a. Both multiple motor and one or more vocal tics have been present at
some time during the illness, though not necessarily concurrently.
b. The tics may wax and wane in frequency but have persisted more
than 1 year since first tic onset
Persistent (Chronic) Motor or Vocal Tic Disorder
a. Single or multiple motor or vocal tics have been present during the
illness, but not motor and vocal.
b. The tics may wax and wane in frequency but have persisted more
than 1 year since first tic onset
e. Criteria have never been meet for Tourette’s disorder
Specify if: with motor tics only or with vocal tics only
Provisional Tic Disorder
a. Single or multiple motor and/or vocal tics
b. The tics have been present for less than 1 year since first tic onset.
e. Criteria have never been met for Tourette’s disorder or persistent
(chronic) motor or vocal tic disorder
Simple motor tics are of short duration (e.g. eye blinking, shoulder
shrugging)
Complex motor tics are of longer duration and can appear purposeful
as:
copropraxia – tic-like sexual or obscene gesture
echopraxia – tic-like imitation of someone else’s movements
palilalia – repeating one’s own sounds or words
echolalia – repeating the last-heard word or phrase
coprolalia – uttering socially unacceptable words, including obscenities,
or ethnic, racial, or religious slurs.
- Males are more commonly affected than females
Other Specified Tic Disorder – This category applies to presentations
in which symptoms characteristic of a tic disorder that cause clinically
significant distress or impairment in social, occupational, or other
important areas of functioning predominate but do not meet full criteria
for a tic disorder or any of the disorders in the neurodevelopmental
disorders diagnostic class.
Unspecified Tic Disorder - there is insufficient information to make a
more specific diagnosis
SCHIZOPHRENIA SPECTRUM AND OTHER
PSYCHOTIC DISORDERS
- these groups of disorders are defined by abnormalities in one or more
of the following five domains:
Delusions
- These are fixed believes that are not amenable to change in light of
conflicting evidence. Their content may include a variety of themes
(persecutory, referential, grandiose, religious, somatic, nihilistic,
erotomatic, and infestation).
- Delusions are deemed bizarre if they are clearly implausible and not
understandable to same-culture peers and do not derive from ordinary
life experiences (thought withdrawal, thought insertion, delusions of
control).
Hallucinations
- These are perception-like experiences that occur without external
stimulus. They are vivid and clear, with the full force and impact of
normal perceptions, and not under voluntary control.
- Auditory hallucinations are the most common.
- These can occur while falling asleep (hypnagogic) or waking up
(hypnopompic).
Disorganized Thinking (Speech)
- Disorganized thinking (formal thought disorder) is typically inferred
from the individual’s speech.
- The individual may switch from one topic to another (derailment or
loose of associations)
- Answers to the questions may be obliquely related or completely
unrelated (tangeniality).
- Incomprehensible speech and resembles receptive aphasia
(incoherence)
Grossly Disorganized or Abnormal Motor Behavior (including
Catatonia)
- It may manifest itself in a variety of ways from childlike “silliness” to
unpredictable agitation.
- Catatonic behavior is marked by a marked decrease in the reactivity
to the environment. This range from resistance to instructions
(negativism); to maintaining a rigid, inappropriate or bizarre posture, to
complete lack of verbal and motor responses (mutism and stupor).It
can also include purposeless and excessive motor activity without
obvious cause (catatonic excitement).
Negative Symptoms
- Diminished emotional expression includes reductions in the
expression of emotion in the face, eye contact, intonation of speech
(prosody), and movements of the hand, head, and face that normally
give an emotional emphasis to speech.
- Avolition is a decrease in motivated and self-initiated purposeful
activities
- Alogia is manifested by diminished speech output.
- Anhedonia is the decreased ability to experience pleasure from
positive stimuli or degradation in the recollection of pleasure previously
experienced.
- Asociality refers to the apparent lack of interest in social interactions.
1) Delusional Disorders
a. presence of 1 or more delusions with duration of 1 month
b. Criterion A for schizophrenia has never been met
c. functioning is not markedly impaired, and behavior is not odd
d. manic or major depressive episodes have been relative to the
duration of the delusional periods
2) Brief Psychotic Disorder
- presence of 1 or more of the ff. symptoms, 1, 2, 3 must be present:
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized or catatonic behavior
- it has a sudden onset, changing from a non-psychotic state to a
clearly psychotic state
- twofold more common in females than in males
3) Schizophreniform Disorder
b. lasts at least 1month but less than 6 months a. at least two, 1, 2, 3
must be present
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized or catatonic behavior
5. negative symptoms
and the individual has already recovered
- provisional if diagnosis must be made without waiting for recovery
c. schizoaffective disorder and depressive bipolar disorders with
psychotic features have been ruled out
- symptomatic presentation equals to that of schizophrenia except for
its duration and the absence of a requirement for a decline in
functioning
4) Schizophrenia
a. At least two, 1, 2, 3 must be present (the same with
schizophreniform).
b. level of functioning in one or more major areas, such as work,
interpersonal relations, and self-care is markedly below the level
achieved prior to onset.
c. disturbances persist for at least 6 months (1 month of prodromal and DEPRESSIVE DISORDERS
residual symptoms characterized by suibtreshold forms of symptoms, - Common features: presence of sad, empty, or irritable mood,
commonly negative symptoms accompanied by somatic and cognitive changes.
- They display inappropriate affect, deficits in inferring the intentions of - What differs among the disorders are issues of duration, timing, or
other people (theory of mind), depersonalization, derealisation presumed etiology
- anxiety and phobias are common
- Schizophrenics lack insight or awareness of their disorder 1) Disruptive Mood Dysregulation Disorder
(anosognosia).
a. severe recurrent temper outbursts manifested verbally and
behaviourally
5) Schizoaffective Disorder c. the temper outbursts occur, on average three or more per week; d.
a. An uninterrupted period of illness during which there is a major and the mood between the temper outbursts is persistently irritable or
mood episode (major depressive or manic) concurrent with Criterion A angry
of schizophrenia. e. and must be present for 12 or more moths; must not have 3 or more
b. Delusions or hallucinations for 2 or more weeks in the absence of a consecutive months symptom-free period
major depressive episode during the lifetime duration of the illness. - more common among school-age children and higher in males
c. Symptoms that meet criteria for a major mood episode are present - cannot co-exist with ODD, IED, Bipolar (episodic)
for the majority of the total duration of the active and residual portions - severe in one area, mild on the other
of the illness.
- dysfunction is not a diagnostic criterion
2) Major Depressive Disorder
- higher in females than in males due to an increased incidence of the
- one major depressive episode
depressive types among females
- Schizoaffective, bipolar type, may be more common in young adults. Dimension MDE Grief/Bereavement
Schizoaffective depressive type may be more common in older adults. depressed mood,
Predominant feelings of emptiness and
inability to anticipate
Affect loss
Catatonia pleasure
- The manual does not treat catatonia as an independent class but dysphoria is likely to
Duration dysphoria is persistent
recognizes: a) catatonia associated with other mental disorder, b) decrease in intensity
with specific preoccupations
catatonic disorder due to a general medical condition, c) unspecified self-critical or
Thought Content and memories of the
catatonia pessimistic ruminations
deceased
- The clinical presentation of catatonia can be puzzling, as the feelings of
psychomotor disturbance may range from marked unresponsiveness to Self-Esteem worthlessness and self- self-esteem is preserved
marked agitation. loathing
1. Stupor (no psychomotor activity)
2. Catalepsy (passive induction of a posture against a gravity) - recurrent if there is no period of two or more months with no
3. Waxy flexibility symptoms, or only one or two symptoms to no more than a mild degree
4. Mutism (no or very little verbal response) - Persistent Complex Bereavement Disorder: The intensity, quality, or
5. Negativism (no response to external stimuli) persistence of grief reactions following a death of a loved one exceeds
6.Posturing (spontaneous and active maintenance of a posture against what normally might be expected when cultural, religious, or age-
gravity) appropriate norms are taken into account.
7. Mannerism (odd, circumstantial caricature of normal actions)
8. Stereotypy (repetitive, abnormally frequent, non-goal directed 3) Persistent Depressive Disorder (Dysthymia)
movements) - associated with the thymus gland
9. Agitation not influenced by external stimuli - represents a consolidation of DSM-IV defined chronic major
10. Grimacing depressive disorder and dysthymic disorder
11. Echolalia (mimicking another’s speech) a. 2 years of dysphoria
12. Echopraxia (mimicking another’s movements) b. only 2 of these symptoms while depressed:
(no 2 months of remission)
- no manic., no hypomanic, and have never met criteria for
cyclothymic
4) Premenstrual Dysphoric Disorder
a. at least five symptoms must be present in the final week before the
onset of menses, start to improve within a few days after the onset
menses, and become minimal or absent in the week postmenses
b.
1. affective lability (rapid change in mood)
2. irritability or anger
3. dysphoria or depressed mood
4. depressed mood
c. MDE + physical symptoms such as breast tenderness or swelling,
joint or muscle pain, sensation of bloating, or weight gain
- If symptoms have not been confirmed by prospective daily ratings of
at least two somatic cycle, “provisional” should be noted after the name
of the diagnosis.
ANXIETY DISORDERS
1) Separation Anxiety Disorder
a. Developmentally inappropriate and excessive fear or anxiety
concerning separation from those to whom the individual is attached,
as evidenced by three of the ff. symptoms:
1. recurrent excessive distress
2. persistent worry about losing the attachment figure and
possible harm to them
3. worry about experiencing an untoward event
4. reluctance or refusal to go out
5. fear of being alone or in other settings
6. refusal to sleep away from home
7. repeated nightmares involving theme of separation
8. repeated complaints of physical symptoms
- the fear, anxiety, or avoidance last 4 weeks for children &
adolescents; 6 weeks for adults
2) Selective Mutism
a. Consistent failure to speak in specific social situations in which there
is an expectation for speaking despite speaking in other situations
c. the failure to speak is not attributable to a lack of knowledge of, or
comfort with the spoken language required in the social situation
3) Specific Phobia
a. marked fear or anxiety about a specific object or situation
b. the phobic object/situation always provoke immediate fear or anxiety
c. the phobic object/situation is actively avoided or endured with fear
d. the fear or anxiety is out of proportion to the actual danger
e. the fear is typically persistent, lasting for 6 months or more
4) Social Anxiety Disorder (Social Phobia)
a. marked fear or anxiety about one or more social situations in which
the individual is exposed to possible scrutiny by others
b. fear of negative evaluation
c. the social situations provoke fear or anxiety
d. avoided or endured with intense fear or anxiety
e. the fear is out of proportion to the actual danger
f. persistent, typically lasing for 6 months or more
5) Panic Attacks
a. A panic attack is an abrupt surge of intense fear or intense
discomfort that reaches a peak within minutes, in which 4 of the 13
cognitive and physical symptoms are required (recurrent unexpected
panic attacks required):
b. worry about additional panic attacks
c. maladaptive change in behavior related to the attacks
- One type unexpected panic attack is a nocturnal panic attack (waking
from sleep in a state of panic).
- Attacks that meet all other criteria but have fewer than four
physical/cognitive symptoms.
- more common in females than males but symptoms do not differ
between males and females.
6) Agoraphobia
a. marked fear or anxiety: 2 out of 5 required
1. using public transportation
2. being in open spaces
3. being in enclosed spaces
4. standing in line or being in a crowd
5. being outside of the home alone
b. fears or avoids the situations because of the thoughts that escape
might be difficult or help might not be available
c. the agoraphobic situation always provoke anxiety
d. actively avoided, endured, or requires a presence of a companion
e. persistent, lasting 6months
- Females are twice as likely as males to experience agoraphobia
7) Generalized Anxiety Disorder
a. excessive anxiety and worry (apprehensive expectation) b. and finds
it difficult to control
c. 3 or more of the ff: for at least 6 months:
1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance
GAD vs. nonpathological anxiety
- excessive and impairing in GAD, while everyday worries are
perceived as manageable
- GAD is more pervasive, pronounced, and distressing, have longer
duration, and occur without precipitant
- GAD is accompanied with physical symptoms
* Females are twice as likely as males to experience GAD
* It is also consistent, it never spikes
OBSESSIVE-COMPULSIVE DISORDER
1) Obsessive-Compulsive Disorders
Obsessions
1. recurrent and persistent thoughts, urges, or images that
are intrusive and unwanted
2. the individual attempts to ignore or suppress to neutralize
compulsion
Compulsions
1. repetitive behaviors that the individual feels driven to
perform in response to the obsessions
2. The behaviors are aimed at preventing or reducing
anxiety (but the behaviors are not related in a realistic way)
b. the obsessions and compulsions are time-consuming
- associated with a dysfunction in the orbitofrontal cortex, anterior
cingulate cortex, and striatum
- males have an earlier age onset of OCD than females and more likely
to have comorbid tic disorder
2) Body Dysmorphic Disorder
- formerly known as dysmorphophobia
a. preoccupation with one or more perceived defects or flaws in
physical appearance that are not observable or appear slight to others
b. has performed repetitive behaviors in response to the appearance
concerns.
3) Hoarding Disorder
a. Persistent difficulty discarding or parting with possessions,
regardless of their actual value.
b. due to the perceived need to save this items and the distress
associated with discarding them
4) Trichotillomania (Hair-Pulling) Disorder
a. recurrent pulling of one’s hair, resulting in hair loss
b. repeated attempts to decrease or stop hair pulling
5) Excoriation (Skin-Picking) Disorder
a. recurrent skin picking resulting in skin lesions
b. repeated attempts to decrease or stop skin picking
TRAUMA- AND STRESSOR-RELATED DISORDER
1) Reactive Attachment Disorder
a. A consistent pattern of inhibited, emotionally withdrawn behavior
toward adult caregivers, manifested by both of the following:
1, 2: minimal seeking and responding to comfort when
distressed
b. persistent social and emotional disturbance characterized by at least
two of the ff:
1. Minimal social and emotional responsiveness to others
2. Limited positive affect
3. Episodes of unexplained irritability, sadness, or
fearfulness that are evident during nonthreatening
interactions with adult caregivers
c. pattern of extremes of insufficient care
1. Social neglect or deprivation
2. Repeated change of primary caregivers
3. Unusual rearing environment
d. Criterion C is the presumed cause for criterion A
e. criteria not met for autism spectrum disorder
- A diagnosis of RAD should not be made in children who are
developmentally unable to form selective attachment. For this reason,
the child must have a developmental age of at least 9 months (also
disinhibited social engagement disorder)
- Serious social neglect is a diagnostic requirement for RAD (ALSO
DSED), and is the only known risk factor of the disorder.
2) Disinhibited Social Engagement Disorder
a. actively approaching and interacting with unfamiliar adults
1. Reduced reticence
2. Overly familiar verbal or physical behavior
3. Diminished or absent checking back with
the adult caregiver after venturing away
4. Willingness to go off with an unfamiliar adult
b. Criterion A is not limited to impulsivity, but includes socially
disinhibited behavior.
c. pattern of extreme insufficient care (abovementioned)
- The signs of the disorder persist despite even after these signs of
neglect are no longer present.
-Course Modifier: Caregiving quality seems to moderate the course of
disinhibited social engagement disorder.
3) Posttraumatic Stress Disorder
Older than 6 years old
A. Exposure to actual or threatened death through
- Direct experience, witnessing, learning from others,
repeated exposure
B. Intrusion symptoms: 1 or more
- memories, dreams, dissociative reactions (flashbacks),
marked psychological reaction to cues, distress upon
exposure
C. Avoidance: 1 or both
- avoidance of memories/thoughts, avoidance of external
reminders of the trauma
D. Negative alterations in cognitions and mood:
- inability to remember an important aspect of the traumatic
event
- exaggerated negative beliefs about oneself
- distorted cognitions about the cause or consequences of
the traumatic events
- persistent negative emotional state
- inability to experience positive emotions
- anhedonia/social withdrawal
- feelings of detachment or estrangement from others
E. Arousal : 2
- irritable behavior and angry outbursts
- reckless or self-destructive behavior
- hypervigilance
- exaggerated startle response
- problems with concentration
- sleep disturbance
F. Duration is more than 1 month.
with dissociative symptoms:
Depersonalization – experiences of feeling detached from, and as if
one were an outside observer of, one’s mental processes or body
Derealization - unreality of surroundings
with delayed expression:
Younger than 6 years old
- only three not four aspects of PTSD (avoidance or negative
mood/cognition combined)
- Emotional reactions to the traumatic event (fear, helplessness, horror)
are no longer a part of Criterion A because the clinical presentation of
PTSD varies.
- PTSD is more prevalent among females than among males.
4) Acute Stress Disorder
- nine of the following symptoms
- 3 days to 1 month.
5) Adjustment Disorder
The development of emotional or behavioral symptoms in response to
an identifiable stressor, occurring within 3months of the onset of the
stressor and last no longer than an additional of 6 months after the
stressor or its consequences have ceased.
d. the symptoms do not represent normal bereavement
e. once the stressor have terminated, the symptoms do not persist for
more than an additional 6 months.
- The stressors can be of any severity.
PERSONALITY DISORDERS
A personality disorder is: an enduring pattern of inner experience and
behavior that deviates markedly from the expectations of the
individual’s culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood and, is stable over time, and leads to
distress or impairment.
DISSOCIATIVE DISORDERS
1) Dissociative Identity Disorder
a. Dissociative disorders are characterized by disruption of and/or
discontinuity in the normal integration of consciousness, memory,
identity, emotion, perception, body representation, motor control, and
behavior.
- Discontinuity in sense of self (voices)
- sense of agency (strong emotions, impulses and speech
or actions without a sense of personal ownership or control
b. Dissociative amnesia
- gaps in remote memory of personal life events
- lapses in dependable memory
- discovering evidence of their forgotten actions and tasks
2) Dissociative Amnesia
a. inability to recall important autobiographical information, usually of a
traumatic or stressful nature, that is inconsistent with ordinary
forgetting
Localized amnesia – a failure to recall events during a circumscribed
period of time, is the most common of dissociative amnesia
Selective amnesia – the individual can recall some, but not all, of the
events during a circumscribed period of time.
Generalized amnesia – a complete loss of memory for one’s life
history, is rare
Systematized amnesia – the individual loses memory for a specific
category of information
Continuous amnesia – an individual forgets each new event as it
occurs
2) Depersonalization/Derealization Disorder
SOMATIC SYMPTOM AND RELATED DISORDERS
1) Somatic Symptom Disorder
a. one or more somatic symptoms that are distressing
b. at least one of the following:
- disproportionate thoughts about seriousness of one’s
symptoms
- high level of anxiety about health or symptoms
- excessive time and energy devoted to these symptoms
c. 6 months
- likely to be higher in females
- usually underdiagnosed in older adults either because certain somatic
symptoms are considered part of normal aging or because illness
worry is considered understandable in older adults who have more
general medical illness than young adults.
2) Illness Anxiety Disorder
a. preoccupation with having or acquiring a serious illness
b. somatic symptoms are not present, if present, mild in intensity
c. high level of anxiety about health
d. performs excessive health-related behaviors
- If the individual has extensive worries about health but no or minimal
somatic symptoms, it may be more appropriate to consider illness
anxiety disorder than somatic symptom disorder
- the preoccupations must not be transient
- should not co-occur during the course of a MDE & health concerns
are not delusional and bizarre in nature
3) Conversion Disorder (Functional Neurological Symptom
Disorder)
a. one or more symptoms of altered voluntary motor or sensory
function
b. incompatibility between the symptom and recognized neurological or
medical conditions
- “functional” refers to abnormal nervous system functioning
- diagnosis requires that the symptom is not explained by neurological
disease
- highly associated with dissociation
4) Psychological Factors Affecting Other Medical
Conditions
a. a medical symptom or condition (other than a mental disorder) is
present
b. psychological or behavioral factors adversely affect the medical
condition in one of the following ways:
1. Influencing the course of the medical condition
2. Interfere with treatment
3. Constitute additional well-established risks
4. Influence the underlying pathophysiology, precipitating or
exacerbating symptoms or necessitating medical attention
5) Factitious Disorder (Imposed on Self or Another)
a. falsification of physical or psychological sign or symptoms, and
induction of injury or disease associated with deception
b. presents himself to others as ill, impaired, or injured
c. The deceptive behavior is evident even in the absence of obvious
external awards
- Malingering is differentiated from factitious disorder by intentional
reporting of symptoms for personal gain (e.g. money, time off work)
DISRUPTIVE, IMPULSE-CONTROL, AND
CONDUCT DISORDERS
1) Oppositional Defiant Disorder
a. A pattern of: (at least 4, 6 months) and exhibited at least one
individual who is not a sibling
- angry/irritable mood
- argumentative/irritable mood
- vindictiveness (within the past 6 months)
* mild (one setting), moderate (at least two), and severe (three or
more)
- pervasiveness = severity of the symptom
- They justify their behavior as a response to unreasonable demands
or circumstances, they typically do not regard themselves as angry or
defiant
- more prevalent in males than in females prior to adolescence
- childhood-onset subtype ODD often leads to conduct disorder
2) Intermittent Explosive Disorder
a. recurrent behavioral outbursts representing a failure to control
aggressive impulses
- verbal or physical aggression (2x a week for3months)
- 3 behavioral outbursts causing damage to properties and
physical assault to animals/individuals (12 months)
b. the magnitude of aggressiveness is grossly out of proportion to the
provocation
c. recurrent outbursts are not premeditated and not committed to
achieve some tangible objective
d. chronological age is at least 6 years
- The outbursts have a rapid onset, and typically last for less than 30
minutes; generally impulsive.
- Children ages 6-18 years should not be diagnosed with IED when
outbursts occur in the context of an adjustment disorder.
- Greater in males than in females
3) Conduct Disorder
a. A repetitive and persistent pattern or behavior in which the basic
rights of others or societal rules are violated. Al least 3 of the 15 criteria
for the past12 months and at least one present in the past 6 months
- Aggression to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious violation of rules
c. If the individual is age 18 years or older, criteria are not met for
antisocial personality disorder
* childhood onset type – 1 symptom before age 10
* adolescent-onset type – no symptom before age 10
* unspecified – But there is not enough information available to
determine whether the onset of the first symptom was before age 10
years
- Individuals with conduct disorder are likely to minimize their conduct
problems. The clinician often must rely on additional informants.
FEEDING AND EATING DISORDERS
1) Pica
a. persistent eating of nonnutritive, nonfood substances over a period
of at least one month
2) Rumination Disorder
a. Repeated regurgitation of food over a period of at least 1 month.
Regurgitated food maybe re-chewed, re-swallowed, or spit out.
3) Avoidant-Restrictive Food Intake Disorder
a. An eating or feeding disturbance as manifested by persistent failure
to meet appropriate nutritional and/or energy needs
4) Anorexia Nervosa
a. restriction of energy intake relative to the requirements, leading to a
significantly low body weight
b. intense fear of gaining weight or becoming fat or persistent
behaviors that interfere with weight gain, even though at significantly
low weight
c. disturbance in the way in which one’s body weight or shape is
experienced, undue influence of body weight on self-evaluation, or
persistent lack of recognition of the seriousness of the current low body
weight
- 18.5 kg/m2 is the lower limit of normal body weight
- less common in males than in females
5) Bulimia Nervosa
a. recurrent episodes of binge eating characterized by:
- eating in a discrete period of time, an amount of food that
is definitely larger than most individuals would eat in a similar period of
time under similar circumstances
- a sense of lack of control over eating during the episode
b. recurrent inappropriate compensatory behaviors in order to prevent
weight gain (self-induced vomiting, misuse of laxatives, diuretics, or
other medications, fasting or exercise)
c. Binge eating and compensatory behaviors (once a week for at least
three months)
d. self –evaluation is unduly influenced by body shape and weight
6) Binge Eating Disorder
a1. Eating in a discrete period of time that is definitely larger than what
most people would eat in a period of time under similar circumstance.
a2. A sense of lack of control over eating during the episode.
b. The binge-eating episode is associated with 3 or more of the ff:
1.Eating much more rapidly than normal
2. Eating until uncomfortably full
3. Eating large amounts when not full
4. Eating alone because of embarrassment
5. Feeling depressed afterward
d. The binge occurs at least once a week for 3 months
Acute episode is a time period in which the symptom criteria are
fulfilled.
Partial remission is a period of time after a previous episode during
which an improvement after a previous episode is maintained and in
which the defining criteria of the disorder are only partially fulfilled.
Full remission is period of time after a previous episode during which
no disorder-specific symptoms are present.
SUBSTANCE-RELATED AND ADDICTIVE
DISORDERS
- Substance-related disorders encompass 10 separate classes of
drugs
- All drugs that are taken in excess have in common direct activation of
the brain reward system, which is involved in the reinforcement of
behaviors and the production of memories
- Self-control or impairments in the inhibitory mechanism is a pre-
disposing factor substance abuse.
- Gambling behaviors activate the brain’s reward system just like those
drugs of abuse – and similar behavioral symptoms.
- The substance related disorders are divided into two: substance use
disorder and substance-induced disorder
SUBSTANCE- RELATED
SUBSTANCE USE DISORDERS
- The word “addiction” is not applied as a diagnostic term in this
classification, but the more neutral term substance use disorder is
used. The term “addiction” is omitted in DSM-5 because of its uncertain
definition and its potentially negative connotation.
- The essential feature of a substance use disorder is a cluster of
cognitive, behavioral, and physiological symptoms indicating that the
individual continues using the substance despite significant substance-
related problems.
- Criterion fits the overall groupings of impaired control (Criteria A; 1-4),
social impairment (5-7), risky use (8-9), and pharmacological criteria
(10-11).
taking the substance in larger amounts or over a long period of time than was
originally intended
expression of persistent desire to cut down or regulate substance use (unsuccessful
efforts)
spending a great deal of time obtaining the substance, using the substance, or
recovering from its effects
craving (intense desire or urge for the drugs)
failure to fulfil major obligations at school, work, or home
continued use despite persistent social or interpersonal problems
social, occupational or recreational activities are given up or reduced
repeated use in situations where it is physically hazardous
continued use despite problems caused by the substance
tolerance
withdrawal

- Severity is based on the number of symptom criteria endorsed.
mild = 2-3 symptoms
moderate = 4-5 symptoms
severe = 6 or more
- In terms of recording, the clinician should use the code that applies to
the class of substances but record the name of the specific substance.
SUBSTANCE-INDUCED DISORDER
- This category does not apply to tobacco
DEPRESSANTS
Alcohol
- stimulates the GABA receptors which may account for its ability to
reduce tension
- increases levels of serotonin and dopamine, which may be the source
for its ability to produce pleasurable effects
- it inhibits glutamate receptors, which may cause the cognitive effects
of alcohol intoxication, such as slowed thinking and memory loss
________________________________________________________
Marijuana (CannabisSativa)
- the most frequently used illicit drug and considered a gateway drug
- active chemical: delta-9-tetrahydrocannabinol (THC)
- changes in emotion, attentional capabilities
- bloodshot, itchy eyes, and increased appetite
- makes them feel relaxed and sociable
- increased blood flow in the brain region associated with emotion
(amygdala & anterior cingulate)
- decreased blood flow in the brain region associated with auditory
attention (temporal lobe)
Therapeutic Effects:
- can reduce nausea
- treatment for discomfort of AIDS and chemotherapy
________________________________________________________
Cannabis Use Disorder
- New to DSM-5 is the recognition of cannabis withdrawal symptoms.
- Signs of acute and chronic use include red eyes, cannabis odor on
clothing, yellowing of finger tips, chronic cough, burning of incense (to
hide the odor) and exaggerated craving and impulse for specific foods,
sometimes at unusual times.
- Early onset of cannabis use is likely related to concurrent other
externalizing problems, most notably conduct disorder symptoms.
Cannabis Intoxication
b. problematic behavioral or psychological changes
c. two or more of the symptoms ff: within 2 hours (within minutes if
smoked not orally ingested) of cannabis use:
1. Conjunctival injection
2. Increased appetite
3. Dry mouth
4.Tachycardia
- with perceptual disturbances: Hallucinations with intact reality testing
or auditory, visual, or tactile illusions occur in the absence of delirium.
- If the clinical presentation includes hallucinations in the absence of
intact reality testing, a diagnosis of substance/medication-induced
psychotic disorder should be considered.
- In contrast to cannabis intoxication, alcohol intoxication and sedative
hypnotic, or anxiolytic intoxication frequently decrease appetite,
increase aggressive behavior, and produce nystagmus (involuntary
eye movement) or ataxia (loss of voluntary muscle coordination).
Phencyclidine also causes perceptual changes but is more likely to
cause ataxia and aggressive behavior.
Cannabis Withdrawal
- at least three of the ff symptoms within 1 week:
1. Irritability, anger, or aggression
2. Nervousness or anxiety
3. Sleep difficulty
4. Decreased appetite or weight loss
5. Restlessness
6. Depressed mood
7. Abdominal pain, shakiness, tremors, sweating, fever, chills, or
headache
- The following may also be observed in addition to criterion B: fatigue,
yawning, difficulty concentrating, and rebound periods of increased
appetite and hypersomnia.
SEDATIVES, HYPNOTICS & ANXIOLYTICS
Barbiturate
- Barbiturates are synthetic sedatives
- stimulates GABA system
- relaxes the muscle, reduce anxiety, and produces a euphoric state
OPIOIDS
- fall under the broad category of sedatives
- include opium and its derivatives : morphine, heroin, and codeine
- this group in moderate doses can relieve pain and induce sleep
- morphine called as “the plant of joy”
- heroin was initially used in cough syrups and more potent than
morphine
Psychological and Physical Effects
- can produce euphoria, drowsiness, and sometimes a lack of
coordination
- stimulates neural receptors of the body’s own opioid system
(endorphins and enkephalins)
- action in the nucleus accumbens (pleasurable effects)
STIMULANTS
- acts on the brain and the sympathetic nervous system to increase
alertness and motor activity.
Amphetamines
- can be taken intravenously or orally
- produce their effects by causing the release of norepiniphrine and
dopamine and blocking their reuptake
- can reduce appetite, wakefulness is heightened
- the person becomes alert, euphoric, and outgoing, with seemingly
boundless energy and self-confidence
- large doses can induce a state quite similar to paranoid schizophrenia
- tolerance develops quickly
- methamphetamines can damage the brain specifically the
hippocampus
Cocaine
- extracted from leaves of coca shrub
- has been used since then as a local anesthetic
- crack, a rock-crystal form of cocaine
Effects
- blocks the reuptake of dopamine in the mesolimbic areas
- can increase sexual desire and produce feelings of self-confidence,
well-being, and indefatigability
- an overdose brings on hallucinations paranoid feelings, nausea,
chills, and insomnia
- Cocaine is a vasoconstrictor, cause blood vessels to narrow
- causes cognitive impairments such as difficulty paying attention and
remembering.
- initial effect is euphoria, then followed by a crash or letdown
HALLUCINOGENS
- hallucinations are recognized by the person as being caused by the
drug, unlike hallucinations in schizophrenia
LSD, d-lysergic diethylamide
- LSD users experience “trip” and expansion of consciousness
- alters a person’s sense of time (it seems to go slowly)
- appreciates sounds and sights like never before but users experience
anxiety after taking
- Other hallucinogens include: mescaline and psilocybin
Ecstasy
- enhances intimacy and insight, improves interpersonal relationships,
elevates mood and self-confidence and promote aesthetic awareness
- PCP or phencyclidine (angel dust)
- developed as tranquilizers
- chronic use is associated with neuropsychological deficits
________________________________________________________
Phencyclidine Use Disorder
- Withdrawal symptoms and signs are not established.
- They produce feelings of separation from mind and body (hence
dissociation)
- Its effects may precipitate a persistent psychotic episode resembling
schizophrenia.
- It is likely to produce dissociative symptoms, analgesia, nystagmus,
and hypertension. Violent behavior can also occur.
Phencyclidine Intoxication
- The most clinical presentations include disorientation, confusion
without hallucinations, hallucinations or delusions, a catatonic-like
syndrome, and coma of varying severity.
- Nystagmus and violent behavior may distinguish intoxication due to
phencyclidine from that due to other substances.
-Phencyclidine is detectable in urine so toxicological test maybe used.
c. two or more of the following:
1. Vertical or horizontal nystagmus
2. Hypertension or tachycardia
3. Numbness or diminished responsiveness to pain
4. Ataxia
5. Dysarthria (difficulty controlling the muscles responsible
for speaking
6. Muscle rigidity
7. Seizures or coma
8. Hyperacusis (oversensitivity to certain frequency and
volume ranges of sound
Other Hallucinogen Intoxication
- diagnostic criteria the same with phencyclidine intoxication
Hallucinogen- Persisting Perception Disorder
- Perceptual symptoms that were experienced while intoxicated with
the hallucinogen (reexperiencing) but reality testing remains intact
- Visual disturbances tend to be predominant (geometric, intensified
colors, misperception of images)
- may last for weeks, months or years
- occurs primarily after LSD use
- Volatile hydrocarbons are toxic gases from glues, fuels, paints, and
other volatile compounds.
Agonistic Drugs – mimic shape, and enhance neurotransmitter
Antagonistic Drugs – fills the site and block neurotransmitters
Alcohol Myopia. Alcohol impairs cognitive processing and narrows
attention to the most immediately available cues.
NEUROCOGNITIVE DISORDERS (NCD)
- The NCD category encompasses the group of disorders in which the
primary clinical deficit is in cognitive function, and that are acquired
rather than developmental.
Delirium
a. disturbance in attention and awareness
b. the disturbance develops over a short period of time (usually hours
to few days) and tends to fluctuate in severity during the course of a
day
c. an additional disturbance in cognition (memory deficit, disorientation,
language, visuospatial ability, or perception)
- The perceptual disturbances accompanying delirium include
misinterpretations, illusions, or hallucinations, and are typically visual.
- The ability to evaluate cognition in delirium depends on there being a
level of arousal sufficient
MANIC EPISODE
- A distinct period of persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or
energy lasting at least 1 week
1. Inflated self-esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual or pressure to keep talking
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility
6. Increased in goal-directed activity
7. Excessive involvement in activities that have a high potential for
painful consequences
HYPOMANIC EPISODE
- A distinct period of persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or
energy lasting at least 4 consecutive days.
MAJOR DEPRESSIVE EPISODE
- Five or more of the following symptoms have been present during the
same 2-week period and present a change from previous functioning;
at least one of the symptoms is either 1 or 2.
1. Depressed mood
2. Markedly diminished interest or pleasure
3. Significant weight loss when not dieting or weight gain
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or guilt
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death
SEXUAL DYSFUNCTION
- For men and women four phases of the sexual response cycle have
been recognized: desire, excitement, orgasm, and resolution
- Sexual dysfunctions are a heterogeneous group of disorders that are
typically characterized by a clinically significant disturbance in a
person’s ability to respond sexually or to experience sexual pleasure.
- Clinical judgment should be used to determine if the sexual difficulties
are the result of inadequate sexual stimulation.
- Subtypes are used to designate the onset of the difficulty. The time of
onset may indicate different etiologies and interventions.
o Lifelong refers to a sexual problem that has been present from
first sexual experiences.
o Acquired applies to sexual disorders that develop after a period of
relatively normal sexual function.
o Generalized refers to sexual difficulties that are not limited to
certain types of simulation, situations, or partners.
o Situational refers to sexual difficulties that only occur with certain
types of stimulation, situations, or partners.
- five factors to be considered during assessment and diagnosis:
(1) partner factors
(2) relationship factors
(3) individual vulnerability factors psychiatric comorbidity, or stressors
(4) cultural/religious factors
(5) medical factors relevant to prognosis, course, or treatment
- - neurotic personality traits (erectile disorder)
- differences in propensity for sexual excitation and sexual inhibition (
- Activation in the mesocephalic transition zone, including the ventral tegmental area
(premature ejaculation)
- drug withdrawal (opioid)
Delayed Ejaculation
a. Either of the following: (must be experienced 75-100% of the time)
1. Marked delay in ejaculation
2. Marked infrequency or absence of ejaculation
Delayed Ejaculation
a. Three of the following:
1. Difficulty in obtaining erection during sexual activity
2. Difficulty in maintaining an erection until the completion of
sexual activity.
3. Marked decrease in erectile rigidity.
- common for men with neurotic personality, alexithymia (deficits in
cognitive processing of emotions), and those diagnosed with
depression and PTSD
Female Orgasmic Disorder
a. Either of the following:
1. Marked delay in, marked infrequency of, or absence of
orgasm
2. Reduced intensity of orgasmic situations
- A woman experiencing orgasm through clitoral stimulation but not
during intercourse does not meet criteria for a clinical diagnosis of
female orgasmic disorder.
Female Sexual Interest/Arousal Disorder
a. lack of, or significantly reduced, sexual interest/arousal (at least
three)
1. Absent /reduced interest in sexual activity (hypoactive
sexual desire disorder)
2. Absent/reduced sexual/erotic thoughts or fantasies
3. No/reduced initiation of sexual activity, unreceptive to
partner’s attempt to initiate
4. Absent/reduced sexual excitement/pleasure
5. Absent/reduced sexual interest/arousal to any internal or
external sexual/erotic cues (responsive sexual desire)
 6. Absent/reduced genital or nongenital sensations during
sexual activity
Genito-Pelvic Pain/Penetration Disorder
a. persistent or recurrent difficulties with one or more of the ff:
1. Vaginal penetration during intercourse
2. Vulvovaginal or pelvic pain during vaginal intercourse or
penetration attempts
3. Fear anxiety of fear in anticipation of pelvic pain
4. Tensing or tightening of the pelvic floor muscles during
attempted vaginal penetration
Male Hypoactive Sexual Desire Disorder
a. deficient sexual/erotic thoughts or fantasises and desire for sexual
activity
- an interpersonal context must be taken into account in diagnosing
this disorder
- It is sometimes associated with erectile and/or ejaculatory concerns
Premature (Early) Ejaculation
a. A persistent or recurrent pattern of ejaculation during partnered
sexual activity within approximately 1 minute following vaginal
penetration and before the individual wishes.
* Specific duration criteria have not been established for nonsexual
activities.
- Ejaculatory latency refers to the elapsed time before ejaculation
GENDER DYSPHORIA
- Gender assignment refers to the initial as male or female. This
usually occurs at birth, thereby, yields the “natal gender”.
- Gender-atypical refers to somatic features or behaviors that are not
typical of individuals with the same assigned gender in a given society
and historical era; for behavior, gender-nonconforming is an
alternative descriptive term.
- Gender reassignment denotes an official (and usually legal) change
of gender.
- Gender identity is a category of social identity and refers to an
individual’s identification as male or female.
- Transgender refers to the broad spectrum of individuals who
transiently or persistently identify with a gender different from their
natal gender.
- Transsexual denotes an individual who seeks, or has undergone, a
social transition from male to female, or female to male, and which
involves a somatic transition by cross-sex hormone treatment and
genital surgery (sex reassignment surgery)
- Gender dysphoria as a general descriptive term refers to an
individual’s affective/cognitive discontent with the assigned gender but
is more specifically defined when used as a diagnostic category. This
refers to the distress that may accompany the incongruence between
one’s experienced or expressed gender and one/s assigned gender.
- The current term is more descriptive than the previous DSM-IV
gender identity disorder and focuses on dysphoria as the clinical
problem, not identity per se.
Children
1. A strong desire to be the other gender or an insistence that one is
the other gender.
2. In boys, a strong preference for cross-dressing or simulating female
attire. In girls, a strong preference for only wearing typical masculine
clothing and strong resistance to wearing feminine clothes.
3. A strong preference for cross-gender roles in make-believe or
fantasy play.
4. A strong preference for the toys, games, or activities stereotypically
used or engaged in by the other gender.
5. A strong preference for playmates of the other gender.
6. In boys, a strong rejection of typically masculine toys, games, and
activities, and a strong avoidance of rough-and tumble play, or in girls,
a strong rejection of typically feminine toys, games, and activities.
7. A strong dislike of one’ sexual anatomy.
8. A strong desire for the primary and/or secondary characteristics of
that much one’s experienced gender.
Adolescents and Adults
1. A marked incongruence between one’s experienced/expressed
gender and primary and/or secondary characteristics.
2. A strong desire to be rid of one’s primary and/or secondary sex
characteristics
3. A strong desire for the primary and/or secondary characteristics of
the other gender.
4. A strong desire to be of the other gender.
5. A strong desire to be treated as the other gender.
6. A strong conviction that one has the typical feelings and reactions of
the other gender.
- Criteria for children are defined in a more concrete, behavioral
manner than those for adolescents and adults.
- Young children are less likely than older children, adolescents, and
adults to express extreme and persistent anatomic dysphoria.
- androphilic (sexually attracted to males); gynephilic (sexually
attracted to females)
- In both adolescent and adult natal males, the common course is the
early-onset form of gender dysphoria. The late-onset form is much less
common in natal females compared with natal males.
PARAPHILIC DISORDERS
- The order of presentation of the listed paraphilic disorders generally
corresponds to common classification schemes for these conditions.
Anomalous Activity Preferences
 Courtship Disorders – resemble distorted components of
human courtship behavior (voyeuristic, exhibitionistic &
frotteuristic)
 Algolagnic Disorders – involve pain and suffering (sexual
masochism and sadism)
Anomalous Target Preferences
 one directed at other humans (pedophilic)
 two directed elsewhere (fetishistic and transvestic)
- The term paraphilia denotes any intense and persistent sexual
interest other than sexual interest in genital stimulation or preparatory
fondling with phenotypically normal, physically mature, consenting
human partners.
- in full remission specifier: the individual has not acted on the urges
and there has been no distress or impairment for at least 5 years in an
uncontrolled environment
Voyeuristic Disorder
a. recurrent and intense sexual interest arousal from observing an
unsuspecting person who is naked, in the process of disrobing, or
engaging in sexual activity, as manifested by fantasies, urges, or
behaviors
b. the individual has acted on these sexual urges with a nonconsenting
person
c. at least 18 years of age
- Adolescence and puberty generally increase sexual curiosity and
activity. To alleviate the risk of pathologizing normative sexual interest
and behavior during pubertal adolescence, the minimum age for the
diagnosis of voyeuristic disorder is 18 years.
- can be applied to individuals who relatively freely disclose this
paraphilia and to those who firmly deny.
Exhibitionistic Disorder
a. recurrent and intense sexual arousal from the exposure of one’s
genital to an unsuspecting person of one’s genitals to an unsuspecting
person, as manifested by fantasies, urges, or behaviors.
Frotteuristic Disorder
a. Recurrent and intense sexual arousal from touching or rubbing
against a nonconsenting person, as manifested by fantasies, urges, or
behaviors.
Sexual Masochism Disorder
a. Recurrent and intense sexual arousal from the act of being
humiliated, beaten, bound, or otherwise made to suffer, as manifested
by fantasies, urges, or behaviors.
- with asphyxiophilia: If the individual engages in the practice of
achieving sexual arousal related to restriction of breathing.
- The extensive use of pornography involving the act of being
humiliated, beaten, bound, or otherwise made to suffer is sometimes
an associated feature of sexual masochism disorder.
Sexual Sadism Disorder
a. Recurrent and intense sexual arousal from the physical or
psychological suffering of another person, as manifested by fantasies,
urges, or behaviors.
- The extensive use of pornography involving the infliction of pain and
suffering is sometimes an associated feature of sexual masochism relationships contribute to different psychological sensitivity to differences in styles of emotional expression, eye contact,
disorder. disorders and body language, which vary across cultures. In certain cultures,
Pedophilic Disorder distress make take the form of pseudo-hallucinations and overvalued
a. Recurrent, intense sexually arousing fantasies, sexual urges or ideas that may present clinically similar to true psychosis but are
Intellectual Disability: Intellectual capacity, education, motivation,
behaviors involving sexual activity with a prepubescent child (13 or normative to the patient’s subgroup.
socialization, personality features, vocational opportunity, cultural
younger) Schizoaffective: overdiagnosis of schizophrenia compared to
experience influence adaptive functioning.
b. The individual has acted on the urges schizoaffective disorder in some populations, so care must be taken to
Autism Spectrum Disorder: Deficits in developing, maintaining, and
c. The individual is at least age 16 years and at least 5 years older ensure a culturally appropriate evaluation that includes both psychotic
understanding relationships should be judge against, norms, and
than the child. and affective symptoms.
culture. Cultural and socioeconomic factors may affect age at
Fetishistic Disorder ________________________________________________________
recognition or diagnosis.
a. Recurrent and intense use of sexual arousal from either the use of ADHD: Cultural variation in attitudes toward interpretations of children’s
nonliving objects or a highly specific focus on nongenital body parts. Bipolar I: Little information exists on specific cultural differences in the
behavior Symptoms vary depending on context within a given setting
c. not limited to articles of clothing used in cross-dressing or devices expression of bipolar I disorder. One possible explanation for this may
Separation Anxiety Disorder: There are cultural variations in which it is
specifically designed for the purpose of tactile genital stimulation. be that diagnostic instruments are often translated and applied in
considered desirable to tolerate separation (e.g. age at which it is
different cultures with no transcultural validation.
expected that offspring should leave the parental home)
________________________________________________________
Selective Mutism: Different language, lack of knowledge of the
Lobes of the Cerebral Hemisphere language
1) Frontal – executive functioning Major Depressive Disorder: There is a substantial cultural difference in
________________________________________________________
2) Occipital – responsible for vision the expression of major depressive disorder; however evidences do
3) Temporal – speech & hearing area not permit simple linkages between particular cultures and the
Specific Learning Disorder: It occurs across languages, cultures, races,
4) Parietal – processing sensory information, language processing likelihood of specific symptoms. Rather, clinician should be aware that
and socioeconomic conditions but may vary in its manifestations
in most countries the majority cases of depression go unrecognized in
according to the nature of the spoken and written symbol systems and
Neurotransmitters primary care settings and that in many cultures; somatic symptoms are
cultural and educational practices.
chemicals that facilitate the transmission of a nerve impulse very likely to constitute the presenting complaint.
________________________________________________________
Premenstrual Dysphoric Disorder is not a culture-bound syndrome and
- neurotransmitter involved in controlling movement & has been observed in individuals in the United States, Europe, India,
Developmental Coordination Disorder: Activities of daily living implies
posture and Asia. It is unclear as to whether rates differ by race.
Dopamine cultural differences necessating consideration of the context in which
- modulates mood and plays a central role in dependency ________________________________________________________
and positive reinforcement the individual is living as well as whether he or she has had appropriate
Specific Phobia: Fears of the dark may be reasonable in a context of
- regulating body temperature, sleep, mood, appetite, and opportunities to learn and practice such activities.
Serotonin ongoing violence, and fear of insects may be disproportionate in
pain Stereotypic Movement Disorder: Culture attitudes toward unusual
settings where insects are consumed in the diet.
- important for sleeping, dreaming, emotions, & behaviors may result in delayed diagnosis. Overall cultural tolerance
Norepinephrine Social Anxiety Disorder: In certain cultures, behaviors that might
attentiveness and attitudes toward unusual behaviors may result in delayed
otherwise appear socially anxious may be considered appropriate in
Epinephrine
- a stress hormone which regulates heart rate and fight- diagnosis.
flight response social situations (might be seen as a sign of respect).
- an inhibitory neurotransmitter that mainly regulates Social Anxiety Disorder: Societies with strong collectivistic orientations
Delusional Disorders: An individual’s cultural and religious background
anxiety may report high levels of social anxiety (e.g. taijinn kyofusho in Japan
GABA must be taken into account in evaluating the possible presence of
- contributes to motor control, vision, and other cortical and Korea characterized by social evaluative concerns. In some
delusional disorder. The content of delusions also varies across
functions societies, shyness (social recitence) is a common personality and is
- a major excitatory neurotransmitter associated with cultural contexts.
Glutamate positively evaluated.
memory and learning ________________________________________________________
Panic Disorder: Cultural expectations may influence the classification
- a widely distributed excitatory neurotransmitter that of panic attacks as expected, or unexpected (consideration of culture-
Acetylcholine triggers muscle contraction and stimulates the excretion Brief Psychotic Disorder: It is important to distinguish symptoms of brief
specific symptoms. Clarification of the details of cultural attributions
of certain hormones psychotic disorder from culturally sanctioned response patterns. Be
may aid in distinguishing expected and unexpected panic attacks.
Endorphins - reduce pain and enhance reinforcement Cultural and religious background must be taken into account when
Agoraphobia: What constitutes avoidance may be difficult to judge
considering whether beliefs are delusional.
across culture and sociocultural contexts. Another is that older adults
SOCIOCULTURAL CONTEXT Schizophrenia: Ideas that appear to be delusional in one culture
are likely to overattribute their fears to age-related constraints and are
maybe commonly held in another. Also, the assessment of
less likely to judge their fears as being out of proportion to the actual
disorganized speech may be made difficult by linguistic variation in
factors such as culture, ethnicity, gender and social risk. Third, individuals with agoraphobia are likely to overestimate
narrative styles across cultures. The assessment of affect requires
danger in relation to panic-like or other bodily symptoms.
Generalized Anxiety Disorder: In some culture, somatic symptoms
predominate the expression of the disorder, whereas other culture
cognitive symptoms rend to predominate. The topic being worried
about can be culture specific. It is important to consider the social and
cultural context when whether worries about certain situations are
excessive.
________________________________________________________
Obsessive Compulsive Disorder: Cultural factors may shape the
content of obsessions and compulsions.
Body Dysmorphic Disorder: Cultural differences in terms of perceiving
physical appearance
________________________________________________________
PTSD: There are cultural variation in terms of the type of traumatic
exposure, the meaning attributed to the traumatic event (and its
subsequent effect on severity) and the ongoing sociocultural context.
The clinical expression of the symptom cluster may vary culturally.
Adjustment Disorders: The context of the individual’s cultural setting
should be taken into account in making the clinical judgment of
whether the individual’s response to a stressor is maladaptive or
whether the associated distress is in excess of what would be
expected. The nature, meaning, and experience of the stressors and
the evaluation of the response to the stressors may vary across
cultures.
________________________________________________________
Dissociative Identity Disorder: Fragmented identities may take the form
of possessing spirits, deities, demons, or animals, or mythical figures in
settings where normative possession is common.
Dissociative Amnesia: In cultures with highly restrictive social
traditions, the precipitants of dissociative amnesia often do not involve
frank trauma. Instead, the amnesia is preceded by severe
psychological stresses or conflicts.
________________________________________________________
Somatic Symptom Disorder: The description of somatic symptoms
varies with linguistic and other local cultural factors. These somatic
presentations have been described as “idioms of distress”. Also,
explanatory models also vary. Seeking treatment is a worldwide
phenomenon and occurs at similar rates among ethnic groups in the
same country. More common in females.
Illness Anxiety Disorder: The diagnosis should be made with caution in
individuals whose ideas about disease are congruent with widely held,
culturally sanctioned beliefs.
Functional Neurological Symptom Disorder: Changes resembling
conversion (and dissociative) symptoms are common in certain
culturally sanctioned rituals. If the symptoms are fully explained within
the particular cultural context and do not result in clinically significant
distress or disability, then the diagnosis of conversion disorder is not
made. More common in females.
Psychological Factors Affecting Other Medical Conditions: Language
and communication style, explanatory models of illness, patterns of
seeking health care, service availability and organization, family &
gender roles, and attitude towards pain and death.
______________________________________________________
Conduct Disorder: Conduct disorder diagnosis may at times be
potentially misapplied to individuals in settings where patterns of
disruptive behavior are viewed as near normative. Therefore, the
context in which the undesirable behaviors should be considered.
Males frequently exhibit stealing, vandalism, and school discipline
problems while females are more likely to exhibit lying, truancy,
running away, substance use, and prostitution.
_______________________________________________________
Pica: In some populations, the eating of earth or other seemingly
nonnutritive substance is believed to be of spiritual, medicinal, or other
social value, or may be a culturally supported or socially normative
practice. Such behavior does not warrant a diagnosis of pica.
Anorexia Nervosa. Most prevalent in post-industrialized and high-
income countries.
________________________________________________________
Substance Use: Some ethnic groups such as Asians may have a low
rate of alcohol abuse because of physiological intolerance, which is
caused by an inherited deficiency in enzyme involved in alcohol
metabolism.
Cannabis Use Disorder: The world’s most commonly used illicit
substance and frequently the first drugs of experimentation.
Acceptance of cannabis for medical purposes varies widely across and
within cultures.
________________________________________________________
Sexual Dysfunction: Clinical judgment about the diagnosis of sexual
dysfunction should take into consideration cultural factors that may
influence expectations or engender prohibitions about the experience
of sexual pleasure. Aging maybe associated with a normative decrease
in sexual response.
Delayed Ejaculation. More common in male Asians
Female Orgasmic Disorder. Women differ in how important orgasm is
to their sexual satisfaction. Inability to reach orgasm is high among
Southeast Asian countries.
Female Sexual Interest/Arousal Disorder: Lower rates of sexual desire
may be more common among East Asian women compared with
European Canadian women.
Genito-Pelvic Pain/Penetration Disorder. In the past, inadequate
sexual education and religious orthodoxy have often been considered
to be culturally related predisposing factors to the DSM-IV diagnosis of
vaginismus.
Male Hypoactive Sexual Desire Disorder. There is a normative age
decline in sexual desire. Guilt about sex may serve as a mediator. Men
do report a significantly higher intensity and frequency of sexual desire
compared with women.
Premature (Early) Ejaculation. Perception of what constitutes a normal
ejaculatory latency is different in many cultures.
CULTURAL REFORMULATION DSM-5
- Culture refers to systems of knowledge, concepts, rules, and
practices that are learned and transmitted across generations.
- Race is a culturally constructed category of identity that divides
humanity into groups based on a variety of superficial physical traits
attributed to some hypothetical intrinsic, biological characteristics.
- Ethnicity is a culturally constructed identity used to define peoples
and communities. It may be rooted in a common history, geography,
language, religion, or other shared characteristics of group, which
distinguish that group from others.
CULTURAL CONCEPTS OF DISTRESS
- This refers to the ways that cultural groups experience, understand,
and communicate suffering, behaviioral problems, or troubling
thoughts, and emotions.
- Three main types of cultural concepts maybe distinguished:
 Cultural syndromes are clusters of symptoms and
attributions that tend to co-occur among individuals in
specific cultural groups, communities, or contexts and that
are recognized locally as coherent patterns of specific
symptoms or syndromes.
 Cultural idioms of distress are ways of expressing
distress that may not involve specific symptoms or
syndromes, but that provide collective, shared ways of
experiencing and talking about personal or social concerns.
 Cultural explanations or perceived causes are labels,
attributions, or features of an explanatory model that
indicate culturally recognized meaning or etiology for
symptoms.
* The three are more relevant to clinical practice than the older
formulation culture-bound syndrome. The term culture-bound
syndrome ignores the fact that clinically important cultural differences
often involve explanations or experience of distress rather than
culturally distinctive configurations of symptoms. Furthermore, it
overemphasizes the local particularity and limited distribution of cultural
concepts of distress.