ABNORMAL PSYCHOLOGY  The diagnostic criteria from DSM-IV-TR and for
DSM-5 found throughout this book are all
ABNORMAL BEHAVIOR IN HISTORICAL CONTEXT
UNDERSTANDING PSYCHOPATHOLOGY
Psychological disorder – a psychological dysfunction within
an individual associated with distress or impairment in
functioning and a response that is not typical or culturally
expected.
 When physically healthy people can’t do simple
tasks such as eating breakfast or studying.
 All three basic criteria must be met; no one criterion
alone has yet been identified that defines the
essence of abnormality.
 Psychological dysfunction refers to a breakdown
in cognitive, emotional, or behavioral functioning.
(Ex. Unnecessary fears in dates that should be fun.)
 Personal Distress – individual is extremely upset.
 Personal Impairment – “if you are so shy that you
find it impossible to date or even interact with people
and you make every attempt to avoid interactions
even though you would like to have friends”
 Atypical or Not Culturally Expected – deviates
from the average or violating social norms. “The
more productive you are in the eyes of society; the
more eccentricities society will tolerate.”
 We accept extreme behaviors by entertainers, such
as Lady Gaga, that would not be tolerated in other
members of our society.
Phobia – a psychological disorder characterized by marked
and persistent fear of an object or situation.
The most widely accepted definition of abnormal behavior is
used in DSM-5 describes behavioral, psychological, or
biological dysfunctions that are unexpected in their cultural
context and associated with present distress and impairment
in functioning, or increased risk of suffering, death, pain, or
impairment. This definition can be useful across cultures and
subcultures if we pay careful attention to what is functional or
dysfunctional (or out of control) in a given society. But it is
never easy to decide what represents dysfunction, and some
scholars have argued persuasively that the health
professions will never be able to satisfactorily define disease
or disorder.
Prototype – A “typical” profile of a disorder—for example,
major depression or schizophrenia—when most or all
symptoms that experts would agree are part of the disorder
are present.
prototypes. This means that the patient may have
only some features or symptoms of the disorder (a
minimum number) and still meet criteria for the
disorder because his or her set of symptoms is close
to the prototype.
 One of the differences between DSM-IV and DSM-5
is the addition of dimensional estimates of the
severity of specific disorders in DSM-5.
THE SCIENCE OF PSYCHOPATHOLOGY
Psychopathology is the scientific study of psychological
disorders.
SCIENTIST-PRACTITIONER – mental health professionals
take a scientific approach to their clinical work.
 Consumer of science – Enhancing the practice
 Evaluator of science – Determining the
effectiveness of the practice
 Creator of science – Conducting research that
leads to new procedures useful in practice.
STUDYING PSYCHOLOGICAL DISORDERS
Clinical Description – unique combination of behaviors,
thoughts, and feelings that make up a specific disorder.
Specify what makes the disorder different from normal
behavior or from other disorders.
 Presenting problem – is a traditional shorthand
way of indicating why the person came to the clinic.
Statistical Data – age of onset, sex ratio, and;
 Prevalence – how many people in the population as
a whole have the disorder.
 Incidence – how many new cases occur during a
given period, such as a year.
Course of Disorder – disorders follow a somewhat individual
pattern.
 Chronic Course – meaning that they tend to last a
long time, sometimes a lifetime. (Ex. Schizophrenia)
 Episodic Course – likely to recover within a few
months only to suffer a recurrence of the disorder at
a later time. (Ex. Mood Disorders; depression)
 Time-limited course – meaning the disorder will
improve without treatment in a relatively short
period.
Onset of Disorder – initial phase of a disease or condition,
in which symptoms first became apparent.
 Acute Onset – they begin suddenly
 Insidious Onset – develop gradually over an
extended period.
Prognosis – anticipated course of a disorder. “the prognosis
is good,” meaning the individual will probably recover, or “the
prognosis is guarded,” meaning the probable outcome
doesn’t look good.
 Developmental Psychology – study of changes in
behavior over time.
 Developmental Psychopathology – study of
changes in abnormal behavior.
 Life-span developmental psychopathology –
Study of abnormal behavior across the entire age
span
Etiology – the study of origins, has to do with why a disorder
begins (what causes it) and includes biological,
psychological, and social dimensions.
Treatment and Causation – treating a disorder may give
some hints about the nature of the disorder and its causes. if
a drug with a specific known effect within the nervous system
alleviates a certain psychological disorder, we know that
something in that part of the nervous system might either be
causing the disorder or helping maintain it but that does not
mean that the lack of specific drug is the cause of the
disorder.
HISTORICAL CONCEPTS OF ABNORMAL BEHAVIOR
Supernatural Traditions – deviant behavior has been
considered a reflection of the battle between good and evil.
All physical and mental disorders were considered the work
of the devil.
Demons and Witches – psychological disorders was seen
as the work of the devil and witches. It followed that
individuals possessed by evil spirits were probably
responsible for any misfortune experienced by people in the
local community. Treatments - Exorcism, shaving the
pattern of a cross in the hair of the victim’s head.
Stress and Melancholy – Insanity was a natural
phenomenon, caused by mental or emotional stress, and that
it was curable. (Disease of Melancholy: Depression)
 Sin of Acedia – sloth, lethargy, and despair.
 Treatments – rest, sleep, and a healthy and happy
environment.
Treatment for Possession – to make the body uninhabitable
by evil spirits; confinement, beatings, and other forms of
torture. Pit full of poisonous snakes might scare the evil spirits
right out of their bodies. Element of shock; dunking in ice-cold
water.
Mass Hysteria – many people behaved in this strange way
at once. Modern Mass Hysteria – may simply demonstrate
the phenomenon of emotion contagion, in which the
experience of an emotion seems to spread to those around
us. If someone nearby becomes frightened or sad, chances
are that for the moment you also will feel fear or sadness.
Mob Psychology – the individual that “causes” a problem
shared a response with the crowd or group.
The Moon and The Stars – Paracelsus: belief that heavenly
bodies affect human behavior and gravitational effects of the
moon on bodily fluids might be a cause of mental disorders.
The Biological Tradition
Hippocrates – Hippocratic Corpus: psychological
disorders could be treated like any other disease.
Psychological disorders might also be caused by brain
pathology or head trauma and could be influenced by
heredity (genetics).
 Hysteria: Somatic symptom disorders – “empty
uterus, wandering womb/uterus “physical symptoms
appear to be the result of a medical problem for
which no physical cause can be found, such as
paralysis and some kinds of blindness.
Galen – Hippocratic-Galenic approach: suggested that
normal and abnormal behavior are related to four bodily
fluids, or humors. Associating psychological disorders with a
“chemical imbalance,”
 Blood; sanguine (heart) – cheerful / optimistic
 Black bile (spleen) – melancholia (depression)
 Phlegm (brain) – apathy and sluggishness but can
also mean being calm under stress.
 Choler or yellow bile (liver) – Choleric; hot tempered.
The four humors were related to the Greeks’ conception of
the four basic qualities: heat, dryness, moisture, and cold.
 Bloodletting and Leeches – the extraction of
blood, are used to rid the body of unhealthy fluids
and restore chemical balance.
The 19th Century: psychological disorders were attributed to
mental or emotional stress, so patients were often treated
sympathetically in a restful and hygienic environment.
Syphilis – is differentiated from other types of psychosis in  Behaviorism – associated with John B. Watson,
that it is caused by a specific bacterium. Penicillin – cure for Ivan Pavlov, and B. F. Skinner, which focuses on
syphilis. General Paresis: patients deteriorated steadily, how learning and adaptation affect the development
becoming paralyzed and dying within 5 years of onset. Louis of psychopathology.
Pasteur’s develops his germ theory of disease, which helps  1943: The Minnesota Multiphasic Personality
identify the bacterium that causes syphilis. Inventory is published.
 1958: Joseph Wolpe effectively treats patients with
John P. Grey – most influential American psychiatrist of the
time. Causes of insanity were always physical. Thus, de- phobias using systematic desensitization based on
emphasizing psychological treatments. Treatments – rest, principles of behavioral science.
diet, and proper room temperature and ventilation.  1946: Anna Freud publishes Ego and the
Mechanisms of Defense.
Development of Biological Treatments  1913: Emil Kraepelin classifies various
psychological disorders from a biological point of
 Electroconvulsive therapy
view and publishes work on diagnosis.
 Insulin Shock Therapy – stimulate appetite in
 1895: Josef Breuer treats the “hysterical” Anna O.,
psychotic patients who were not eating, but it also
leading to Freud’s development of psychoanalytic
seemed to calm them down. (overdose might result
theory.
to coma or death but some are recovered that is why
it is “shock”) The Present: The Scientific Method and an Integrative
 Opium – used as sedatives Approach
 Neuroleptics (major tranquilizers), for the first time
With the increasing sophistication of our scientific tools, and
hallucinatory and delusional thought processes;
new knowledge from cognitive science, behavioral science,
these drugs also controlled agitation and
and neuroscience, we now realize that no contribution to
aggressiveness.
psychological disorders ever occurs in isolation. Our
 Benzodiazepines (minor tranquilizers), which
behavior, both normal and abnormal, is a product of a
seemed to reduce anxiety.
continual interaction of psychological, biological, and social
 Bromides – class of sedating drugs, treats anxiety.
influences.
The Psychological Tradition – psychological, social and
Extra:
cultural influences on the causation of psychopathology.
Delusion of Persecution – believing that everyone is
Moral Therapy – encouraged and reinforced normal social
plotting against you
interaction. Provide social and interpersonal contact.
Relationships were carefully nurtured. Patients with Delusion of Grandeur – believing that you are God
psychological disorders were freed from chains and shackles
Ideas of reference – in which everything everyone else does
as a result of the influence of Philippe Pinel, a pioneer in
somehow relates back to the individual.
making mental institutions more humane and moral therapy.
Delusions –psychological disorders characterized in part by
Asylum Reform and Decline of Moral Therapy
beliefs that are not based in reality
 Moral therapy worked best when the number of
Hallucination – perceptions that are not based in reality. are
patients in an institution was 200 or fewer.
things a person sees or hears when those things really there
 Moral therapy has an unlikely source. Dorothea Dix
aren’t.
– Mental Hygiene Movement – campaigned
endlessly for reform in the treatment of insanity.
 Brain Pathology and Understaff
Emergences of Different Schools of Psychology
 Psychoanalysis – elaborate theory of the structure
of the mind and the role of unconscious processes
in determining behavior.
 INTEGRATIVE APPROACH TO PSYCHOPATHOLOGY
One-Dimensional – attempts to trace the origins of
behavior to a single cause.
Multidimensional Models – systematic: it implies that any
particular influence contributing to psychopathology.
Behavioral Influences – classic, operant or any other
behavior evoking conditioning.
Biological Influences – brain and the chemicals.
Emotional Influences – can affect physiological responses
such as blood pressure, heart rate, and respiration. Emotions
also changed the way people thought about situations
involving traumatic incidence and motivated them to behave
in ways they didn’t want to.
Social Influences – Social and cultural factors make direct
contributions to biology and behavior such as rejection, and
anxiety of the person to the society around him/her.
Developmental Influences – One more influence affects us
all—the passage of time. As time passes, many things about
ourselves and our environments change in important ways,
causing us to react differently at different ages. Thus, at
certain times we may enter a developmental critical period
when we are more or less reactive to a given situation or
influence than at other times.
THE INTERACTION OF GENE AND THE ENVIRONMENT
Diatheses-Stress Model – individuals inherit tendencies to
express certain traits or behaviors, which may then be
activated under conditions of stress. A condition that makes
someone susceptible to developing a disorder.
The Gene–Environment Correlation Model – genetically
determined tendency to create the very environmental risk
factors that trigger a genetic vulnerability. Example: some
people are genetically vulnerable to depression so they may
tend to seek out difficult relationships or other circumstances
that lead to depression.
Epigenetics and the Nongenomic “Inheritance” of
Behavior – people will still shape their own genetic material
even with the same environment. It seems that genes are
turned on or off by cellular material that is located just outside
of the genome and that stress, nutrition, or other factors can
affect this epigenome, which is then immediately passed
down to the next generation.
NEUROSCIENCE AND ITS CONTRIBUTION TO
PSYCHOPATHOLOGY
The Central Nervous System – processes all information
received from our sense organs and reacts as necessary.
 Spinal Cord – facilitate the sending of messages to
and from the brain. Most complex organ in the body.
 Neurons – control every thought and action. ( An
average of 140 billion nerve is found in the brain.)
 Glia or Glial Cells – outnumber neurons by a ratio
of about 10 to 1. Passive cells that merely served to
connect and insulate neurons. Serve to modulate
neurotransmitter activity.
Parts of a Neuron
 Dendrites – have numerous receptors that receive
messages in the form of chemical impulses from
other nerve cells, which are converted into electrical
impulses.
 Axon – transmits these impulses to other neurons.
 Synaptic cleft – space between the axon of one
neuron and the dendrite of another. This space is of
great interest to psychopathologists.
 Neurotransmitters – biochemicals that are
released from the axon and transmit the impulse to
the dendrite receptors of another neuron.
The Structure of the Brain
Hindbrain – Regulates many automatic activities. Lowest
part of brain stem.
 Cerebellum – controls motor coordination.
Suggests that abnormalities in the cerebellum may
be associated with the psychological disorder
autism.
 Pons – “bridge”, body movement, respiration,
attention, sleep, arousal.
 Medulla – Oblong area; heartbeat and respiration;
sleeping, sneezing, coughing.
Midbrain – coordinates movement with sensory input.
 Reticular activating system – contributes to
processes of arousal and tension, such as whether
we are awake or asleep.
Forebrain
 Thalamus and hypothalamus – which are involved
broadly with regulating behavior and emotion.
Located at the top of the brain stem.
At the Base of Forebrain:
 Limbic System – Limbic means border, so named
because it is located around the edge of the center
of the brain. figures prominently in much of
psychopathology, includes such structures as the
hippocampus (sea horse), cingulate gyrus (girdle),
septum (partition), and amygdala (almond). This
system helps regulate our emotional experiences
and expressions and, to some extent, our ability to
learn and to control our impulses. It is also involved
with the basic drives of sex, aggression, hunger, and
thirst.
 Basal Ganglia – include the caudate (tailed)
nucleus. control motor activity. Damage to this make
us change our posture or twitch or shake.
 Cerebral Cortex – largest part, contains more than
80% of all neurons in CNS. provides us with our
distinctly human qualities, allowing us to look to the
future and plan, to reason, and to create.
 Left Hemisphere – responsible for verbal
and other cognitive processes.
 Right Hemisphere – perceiving the world
around us and creating images.
Each hemisphere consists of four separate areas or Lobes:
 Temporal lobe – recognizing various sights and
sounds and with long-term memory storage.
 Parietal lobe – recognizing various sensations of
touch and monitoring body positioning
 Occipital lobe – integrating and making sense of
various visual inputs.
 Frontal lobe – most interesting from the point of
view of psychopathology. synthesizes all information
received from other parts of the brain and decides
how to respond. It is what enables us to relate to the
world around us and the people in it—to behave as
social animals.
 Prefrontal Cortex – The front (or anterior)
of the frontal lobe, responsible for higher
cognitive functions such as thinking and
reasoning, planning for the future, as well
as long-term memory.
When studying areas of the brain for clues to
psychopathology, most researchers focus on the frontal lobe
of the cerebral cortex, as well as on the limbic system and the
basal ganglia.
The Peripheral Nervous System – coordinates with the
brain stem to make sure the body is working properly.
Somatic nervous system – controls the muscles. SAME.
Autonomic nervous system – regulate the cardiovascular
system (the heart and blood vessels) and the endocrine
system, and to perform various other functions, including
aiding digestion and regulating body temperature.
 Sympathetic nervous system – mobilizing the
body during times of stress or danger by rapidly
activating the organs and glands under its control.
 Parasympathetic nervous system – to balance the
sympathetic system. Normalizing our arousal and
facilitating the storage of energy by helping the
digestive process.
Endocrine System – Each endocrine gland produces its
own chemical messenger, called a hormone, and releases it
directly into the bloodstream. Endocrine regulation may play
a role in depression, anxiety, schizophrenia, and other
disorders
 Adrenal glands – produce epinephrine (also called
adrenaline) in response to stress.
 Thyroid gland – produces thyroxine, which
facilitates energy metabolism and growth.
 Pituitary – master gland that produces a variety of
regulatory hormones.
 Gonadal glands – produce sex hormones such as
estrogen and testosterone.
Psychoneuroendocrinology – interdisciplinary area of
research that nervous system and endocrine system both
play roles in treating psychological disorder.
hypothalamic–pituitary–adrenocortical – hypothalamus
connects to the adjacent pituitary gland, stimulate the cortical
part of the adrenal glands, then surges of epinephrine tend to
energize us, arouse us, and get our bodies ready for threat
or challenge.
Neurotransmitters – brain circuits. More than 100 different
neurotransmitters, each with multiple receptors, are
functioning in various parts of the nervous system. Two types
of neurotransmitters: Monoamines and Amino Acids.
Neurotransmitter function focuses primarily on what happens
when activity levels change:
 Agonists – effectively increase the activity of a
neurotransmitter by mimicking its effects.
 Antagonists – decrease/block, a neurotransmitter.
 Inverse agonists – produce effects opposite to
those produced by the neurotransmitter
Reuptake – After a neurotransmitter is released, it is quickly
drawn back from the synaptic cleft into the same neuron.
Amino-acids Neurotransmitters: “Chemical Brothers”
Glutamate – excitatory transmitter that “turns on” many
different neurons, leading to action.
 Monosodium glutamate (MSG) – increase the
amount of glutamate in the body, causing
headaches, ringing in the ears, or other physical
symptoms in some people.
Gamma-aminobutyric acid (GABA) – an inhibitory
neurotransmitter. To inhibit (or regulate) the transmission of
information and action potentials. Reduces postsynaptic
activity. Best-known effect is to reduce anxiety, reduce overall
arousal somewhat and to temper our emotional responses.
 Benzodiazepines – makes it easier for GABA
molecules to attach themselves to the receptors of
specialized neurons. (makes you calmer).
 ↑ GABA = Treatment for insomnia.
 ↓ GABA = excessive anxiety, insomnia, tremors, and
seizures.
Monoamine Neurotransmitters:
Serotonin – technical name for serotonin is 5-
hydroxytryptamine (5HT). Influence a great deal of our
behavior, mood and particularly the way we process
information.
 ↓ Serotonin = instability, impulsivity, and the
tendency to overreact to situations, aggression and,
excessive sexual behavior and suicidal. Depression.
 Major serotonin pathways in the brain: Cerebral
cortex, Thalamus, Basal ganglia, Dorsal raphe
nucleus, Midbrain and Cerebellum.
 Prozac – enhances serotonin’s effects by preventing
it from being absorbed; have been recalled by the
FDA for dangerous cardiovascular side effects.
Norepinephrine – “noradrenaline”, controls basic bodily
functions such as respiration. Influence the emergency
reactions or alarm responses
 ↑ Norepinephrine = depression
Dopamine – also termed a catecholamine.
 Dopamine has been implicated in the
pathophysiology of schizophrenia and disorder of
addiction.
 Two major dopamine pathways: mesolimbic system
is apparently implicated in schizophrenia; basal
ganglia contributes to problems in the locomotor
system, such as tardive dyskinesia, which
sometimes results from use of neuroleptic drugs.
 L-dopa – a dopamine agonist (increases levels of
dopamine). has been successful in reducing some
of motor disabilities.
 ↓ Dopamine = Parkinson’s Disease.
________________________________________________
Acetylcholine (Ach) – enables muscle action, learning, and
memory.
 Linked with Alzheimer’s Disease, Ach producing
deteriorate.
Extra:
Multidimensional integrative approach – To identify the
causes of various psychological disorders, we must consider
the interaction of all relevant dimensions: genetic
contributions, the role of the nervous system, behavioral and
cognitive processes, emotional influences, social and
interpersonal influences, and developmental factors.
Genetic Contributions to Psychopathology
The genetic influence on much of our development and most
of our behavior, personality, and even IQ score is polygenic—
that is, influenced by many genes. This is assumed to be the
case in abnormal behavior as well, although research is
beginning to identify specific small groups of genes that relate
to some major psychological disorders.
Behavioral and Cognitive Science
The relatively new field of cognitive science provides a
valuable perspective on how behavioral and cognitive
influences affect the learning and adaptation each of us
experience throughout life. Clearly, such influences not only
contribute to psychological disorders but also may directly
modify brain functioning, brain structure, and even genetic
expression. We examined some research in this field by
looking at learned helplessness, modeling, prepared
learning, and implicit memory.
Emotions
Emotions have a direct and dramatic impact on our
functioning and play a central role in many disorders. Mood,
a persistent period of emotionality, is often evident in
psychological disorders.
Cultural, Social, and Interpersonal Factors
Social and interpersonal influences profoundly affect both
psychological disorders and biology.
Life-Span Development
In considering a multidimensional integrative approach to
psychopathology, it is important to remember the principle of
equifinality, which reminds us that we must consider the
various paths to a particular outcome, not just the result.
 CLINICAL ASSESMENT AND DIAGNOSIS
Assessing Psychological Disorders
Clinical assessment – systematic evaluation and
measurement of psychological, biological, and social factors
in an individual presenting with a possible psychological
disorder.
Diagnosis – process of determining whether the particular
problem afflicting the individual meets all criteria for a
psychological disorder, as set forth in the fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders, or
DSM-5.
Key Concepts in Assessment – The process of clinical
assessment in psychopathology has been likened to a funnel.
That it collects a large amount of information then filters it to
necessary information or pinpoint problems that are relevant.
Value of Assessments:
 Reliability – degree to which a measurement is
consistent. That presenting the same symptoms to
different physicians will result in similar diagnoses.
 Interrater reliability – repetitive question
that will get the same answer.
 Test–retest reliability – you will get the
same result even after you tested it a month
ago.
 Validity – measures what it is designed to measure.
 Concurrent or descriptive validity –
Comparing the results of an assessment
measure under consideration with the
results of others. (Orig. and brief version)
 Predictive validity – how well your
assessment tells you what will happen in
the future. (Ex. IQ Test)
 Standardization – a certain set of standards or
norms is determined for a technique to make its use
consistent across different measurements. (Ex. if
you are an African American male, 19 years old, and
from a middle-class background, your score on a
psychological test should be compared with the
scores of others like you and not to the scores of
different people.)
METHODS IN CLINICAL ASSESSMENT
The Clinical Interview – The clinical interview, the core of
most clinical work. Gathers information on current and past
behavior, attitudes, and emotions, as well as a detailed
history of the individual’s life in general and of the presenting
problem.
Mental Status Exam – organize information obtained during
an interview. involves the systematic observation of an
individual’s behavior. How people think, feel, and behave and
how these actions might contribute to or explain their
problems. The Five Categories:
 Appearance and behavior – clinician notes any
overt physical behaviors, individual’s dress, general
appearance, posture, and facial expression.
 Thought Process – rate or flow of speech
(slow/fast), continuity of speech (sense of ideas).
Thought content (delusion, hallucination
 Mood and Affect – Mood is the predominant feeling
state of the individual.(Does the person appear to be
down, depress, hopeless, or pervasive?). Affect to
the feeling state that accompanies what we say at a
given point. (appropriate; we laughed on jokes and
that we don’t cry on it. Blunted or flat: talking about
a range of happy and sad things with no affect
whatsoever.)
 Intellectual Functioning – reasonable vocabulary,
abstractions and metaphors, memory.
 Sensorium – general awareness of our
surroundings. (Does the individual knows the date,
what time it is, where he or she is, who he or she is,
and who you are.)
Semi-structured Clinical interviews – are made up of
questions that have been carefully phrased and tested to
elicit useful information in a consistent manner so that
clinicians can be sure they have inquired about the most
important aspects of particular disorders.
Physical Examination – medical conditions and drug use
and abuse that may contribute to the kinds of problems
described by the patient. That is why Physical Examination is
important to determine if the cause of the disorder is really a
psychological or merely a physical.
  Temporary Toxic State – Many problems
presenting as disorders of behavior, cognition, or
mood may not be a indicator of psychological
disorder. It just that these presenting problems could
be caused by bad food, the wrong amount or type of
medicine, or onset of a medical condition.
Behavioral Assessment – process one step further by
using direct observation to assess formally an individual’s
thoughts, feelings, and behavior in specific situations or
contexts. (Applicable to those who are not old enough or
skilled enough to report their problems and experiences.)
Stimulation or Roleplay – Most clinicians assume that a
complete picture of a person’s problems requires direct
observation in naturalistic environments. But going into a
person’s home, workplace, or school isn’t always possible or
practical, so clinicians sometimes arrange analogue, or
similar, settings – this implies that whatever a patient comes
by and described their presenting problem. It is not entirely
sure it is the truth so you always seek for a bigger picture of
the problem.
The ABCs of Observation
Observational assessment is usually focused on the here and
now. Clinician’s attention is usually directed to the immediate
behavior:
 its antecedents (what happened just before the
behavior)
 its consequences (what happened afterward)
Example: an observer would note that the sequence of
events was (1) his mother asking him to put his glass in the
sink (antecedent), (2) the boy throwing the glass (behavior),
and (3) his mother’s lack of response (consequence). This
antecedent–behavior–consequence sequence (the ABCs)
might suggest that the boy was being reinforced for his violent
outburst by not having to clean up his mess. And because
there was no negative consequence for his behavior (his
mother didn’t scold or reprimand him), he will probably act
violently the next time he doesn’t want to do something.
 Informal Observation – relies on the observer’s
recollection, as well as interpretation, of the events.
 Formal observation – involves identifying specific
behaviors that are observable and measurable
(called an operational definition: the meaning of
the variable in a specific context or observation.)
Self-Monitoring – People can also observe their own
behavior to find patterns or self-observation. The goal here is
to help clients monitor their behavior more conveniently (such
a person who has bulimia who needs to self-monitor their
selves.)
 Checklists and behavior rating scales – which are
used as assessment tools before treatment and then
periodically during treatment to assess changes in
the person’s behavior
 Reactivity – Any time you observe how people
behave; the mere fact of your presence may cause
them to change their behavior.
Psychological testing – We are interested in these tests
because we want to understand better why we and our
friends behave the way we do. Include specific tools to
determine cognitive, emotional, or behavioral responses that
might be associated with a specific disorder and more
general tools that assess longstanding personality features.
 Intelligence testing – determine the structure and
patterns of cognition.
 Neuropsychological testing – determines the
possible contribution of brain damage or dysfunction
to the patient’s condition.
 Neuroimaging – uses sophisticated technology to
assess brain structure and function.
Projective Testing – variety of methods in which ambiguous
stimuli, such as pictures of people or things, are presented to
people who are asked to describe what they see. The theory
here is that people project their own personality and
unconscious fears onto other people and things and, without
realizing it, reveal their unconscious thoughts to the therapist.
(rely heavily on theory of interpretation.)
 Rorschach inkblot test – 10 inkblots
 Comprehensive System – Exner developed a
standardized version of the Rorschach inkblot.
 Thematic Apperception Test (TAT) – a series of
31 cards: 30 with pictures on them and 1 blank card.
The instructions for the TAT ask the person to tell a
dramatic story about the picture.
Personal Inventories – self-report questionnaires that
assess personal traits.
 Face validity – The wording of the questions seems
to fit the type of information desired.
 Minnesota Multiphasic Personality Inventory
(MMPI) – most widely used in the United States.
Empirical approach, that is, the collection and
evaluation of data. The administration of the MMPI
is straightforward. The individual being assessed
 reads statements and answers either “true” or
“false.”.
 MMPI profile – summary of scores from an
individual being clinically assessed.
Intelligence Testing – measured the skills, children need to
succeed in school, including tasks of attention, perception,
memory, reasoning, and verbal comprehension.
 Stanford-Binet test
 The test provided a score known as an intelligence
quotient, or IQ. Initially, IQ scores were calculated by
using the child’s mental age.
 Deviation IQ – A person’s score is compared only
with scores of others of the same age. The IQ score,
then, is an estimate of how much a child’s
performance in school will deviate from the average
performance of others of the same age
 Verbal scales – which measure vocabulary,
knowledge of facts, short-term memory, and verbal
reasoning skills
 Performance scales – which assess psychomotor
abilities, nonverbal reasoning, and ability to learn
new relationships.
Neuropsychological Testing – this method of testing
assesses brain dysfunction by observing the effects of the
dysfunction on the person’s ability to perform certain tasks.
 Bender Visual–Motor Gestalt Test – often used in
children where they copy the given cards to them.
 False Positive – times when the test shows a
problem when none exists
 False Negative – times when no problem is found
even though some difficulty is present
NEUROIMAGING: PICTURES OF THE BRAIN
Neuroimaging – ability to look inside the nervous system
and take increasingly accurate pictures of the structure and
function of the brain.
Image of Brain Structure:
 X-rays
 CAT scan or CT Scan – computerized axial
tomography: locating abnormalities in the structure
or shape of the brain such as tumors.
 Nuclear Magnetic resonance imaging (MRI) –
places a person in a magnetic field and uses radio
waves to cause the brain to emit signals that reveal
shifts in the flow of blood, which, in return, indicate
brain activity.
Images of Brain Functioning:
 Positron emission tomography (PET) scan –
injects a radioactive tracer into the bloodstream and
assesses activity of parts of the brain according to
the amount of glucose they metabolize.
 Single photon emission computed tomography
(SPECT) – works much like PET, although a
different tracer substance.
 Functional MRI, or fMRI – enables researchers to
observe the brain “while it works” by taking repeated
scans.
Psychophysiological Assessment – measurable changes
in the nervous system that reflect emotional or psychological
events.
Electroencephalogram (EEG) – Measuring electrical
activity in the head related to the firing of a specific group of
neurons reveals brain wave activity.
 A person’s brain waves can be assessed in both
waking and sleeping states.
 Alpha Waves – a normal, healthy, relaxed adult,
waking activities are characterized by a regular
pattern of changes in voltage.
 Event-related potential (ERP) or evoked potential
– patterns are recorded in response to specific
events such as hearing a psychologically meaningful
stimulus.
Electrodermal responding – formerly referred to as
galvanic skin response (GSR), which is a measure of sweat
gland activity controlled by the peripheral nervous system.
Biofeedback – levels of physiological responding, such as
blood pressure readings, heartbeat, respiration.
DIAGNOSING PSYCHOLOGICAL DISORDER
Idiographic strategy – determine what is unique about an
individual’s personality, cultural background, or
circumstances.
Nomothetic strategy – able to determine a general class of
problems to which the presenting problem belongs.
Attempting to name or classify the problem.
 Classification construct groups or categories and to
assign objects or people to these categories on the
basis of their shared attributes or relations.
 Taxonomy – classification of entities for scientific
purposes such as insects, or animals.
  Nosology – apply a taxonomic system to
psychological or medical phenomena or other
clinical areas.
 Nomenclature – names or labels of the disorders
that make up the nosology.
 DSM-5 – to identify a specific psychological disorder
in the process of making a diagnosis.
Classical or Pure Categorical Approach – assume that
every diagnosis has a clear underlying pathophysiological
cause, such as a bacterial infection or a malfunctioning
endocrine system. (Essential)
Dimensional Approach – we note the variety of cognitions,
moods, and behaviors with which the patient presents and
quantify them on a scale.(Nonessential)
if someone were to ask you to describe a dog, you could
easily give a general description (the essential, categorical
characteristics), but you might not exactly describe a specific
dog. Dogs come in different colors, sizes, and even species
(the nonessential, dimensional variations)
Prototypical Approach – identifies certain essential
characteristics of an entity so that you (and others) can
classify it. (Essential and nonessential)
Diagnosis before 1980
Emil Kraepelin – Early efforts to classify psychopathology
arose out of the biological tradition. Identified Dementia
Praecox (Schizophrenia); deterioration of the brain that
sometimes occurs with advancing age (dementia) and
develops earlier than it is supposed to, or “prematurely”
(praecox). He also identified manic depressive psychosis
what we known now as bipolar disorder.
WHO added a section classifying mental disorders to the
sixth edition of the International Classification of Diseases
and Related Health Problems (ICD). Diagnostic and
Statistical Manual (DSM-I), published in 1952 by the
American Psychiatric Association. Diagnostic and Statistical
Manual (DSM-II). In 1969.
DSM-III and DSM-III-R – Diagnostic and Statistical Manual
(DSM-III) (1980) – Under the leadership of Robert Spitzer.
 Take an atheoretical approach to diagnosis, relying
on precise descriptions of the disorders rather
psychoanalytic or biological theories
Multiaxial System – allowed clinicians with possible
psychological disorders to be rated on five dimensions, or
axes.
 Axis I: Schizophrenia or mood disorder
 Axis II: Chronic disorders of personality
 Axis III: Physical disorders and conditions
 Axis IV: Amount of psychosocial stress the person
reported
 Axis V: Current level of adaptive functioning
DSM-IV and DSM-IV-TR
 ICD-10
 DSM-IV (1994) task force decided to rely as little as
possible on a consensus of experts.
 12 independent studies or field trials examined the
reliability and validity of alternative sets of definitions
or criteria and, in some cases, the possibility of
creating a new diagnosis.
 Most substantial change in DSM-IV was that the
distinction between organically based disorders and
psychologically based disorders that was present in
previous editions was eliminated.
The Multiaxial Format in DSM-IV
 Axis I: Pervasive developmental disorders, learning
disorders, motor skills disorders, and
communication disorders
 Axis II: Personality disorders & intellectual disability.
 Axis III: Physical disorders and conditions
 Axis IV: Reporting psychosocial and environmental
problems
 Axis V: Current level of adaptive functioning
DSM-5 (2013)
 In collaboration with international leaders working
simultaneously on ICD-11 (2014)
 New disorders are introduced and other disorders
have been reclassified
 There have been some organizational and structural
changes in the diagnostic manual itself: the manual
is divided into three main sections.
 1st: introduces the manual and describes
how best to use it.
 2nd: presents the disorders themselves
 3rd: descriptions of disorders or conditions
that need further research before they can
qualify as official diagnoses.
 Removal of the multiaxial system
 The use of dimensional axes for rating severity,
intensity frequency, or duration of specific disorders
has also been substantially expanded.
Extras:
Appearance and Behavior: slow and effortful motor behavior,
sometimes referred to as psychomotor retardation, may
indicate severe depression.
Thought Process – In some patients with schizophrenia, a
disorganized speech pattern, referred to as loose association
or derailment, is quite noticeable.
 Brief Mental Status Exam (MSE) Form

1. Appearance casual dress, normal grooming and

hygiene other (describe):

2. Attitude calm and cooperative

other (describe):

3. Behavior no unusual movements or psychomotor changes

other (describe):

4. Speech normal rate/tone/volume w/out pressure

other (describe):
5. Affect reactive and mood congruent normal range
labile depressed
tearful constricted
blunted flat
other (describe):

6. Mood euthymic anxious

irritable depressed
elevated
other (describe):

7. Thought Processes goal-directed and logical

disorganized other (describe):
8. Thought Content Suicidal ideation: Homicidal ideation:
None passive active None passive active

If active: yes no If active: yes no

plan plan
intent intent
means means
delusions obsessions/ compulsions
phobias
other (describe):

9. Perception no hallucinations or delusions during interview

other (describe):

10. Orientation Oriented: time place person self

other (describe):
11. Memory/ Concentration short term intact long term intact
other (describe): distractable/ inattentive

12. Insight/Judgement good fair poor

Practitioner Signature Date

Patient Name ID#

http://www.apshealthcare.com/provider/documents/brief_mental_status.pdf
 ANXIETY, TRAUMA AND STRESSOR-RELATED, AND
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
Anxiety is a negative mood state characterized by bodily
symptoms of physical tension and by apprehension about the
future. We cannot predict or control upcoming events. All
Anxiety disorders discussed are characterized by excessive
anxiety, which takes many forms.
Fear – is an immediate emotional reaction to current danger
characterized by strong escapist action tendencies and,
often, a surge in the sympathetic branch of the autonomic
nervous system.
Panic – experience the alarm response of fear when there is
nothing to be afraid of.
Panic attack is defined as an abrupt experience of intense
fear or acute discomfort, accompanied by physical symptoms
that usually include heart palpitations, chest pain, shortness
of breath, and, possibly, dizziness. Two types: expected (you
are afraid of high places or of driving over long bridges) and
unexpected (you don’t have a clue when or where the next
attack will occur) Fear occurring at an inappropriate time.
Causes of Anxiety and Related Disorders
Comorbidity – co-occurrence of two or more disorders in a
single individual.
ANXIETY DISORDERS
Generalized Anxiety Disorder (GAD) – Excessive anxiety
and worry (apprehensive expectation) on minor, everyday
events and not major, occurring more days than not for at
least 6 months about a number of events or activities (such
as work or school performance). The individual finds it difficult
to control the worry
 Statistics: prevalent among older adults and
women least common in the youngest group
 Course of Disorder: Chronic
 Onset of Disorder: insidious
Panic Disorder – experience severe, unexpected panic
attacks; they may think they’re dying or otherwise losing
control. (Present at least two weeks and followed by a month
or more). anxiety is focused on the next panic attack
 Statistics: decreases among the elderly and
prevalent on women
 Course of Disorder:
 Onset of Disorder: insidious
Agoraphobia – fear and avoidance of situations in which a
person feels unsafe or unable to escape to get home or to a
hospital in the event of a developing panic symptoms or other
physical symptoms. Fear or anxiety on:
 Using public transportation
 Being in open space (e.g. mall)
 Being in enclosed spaces (e.g. theater)
 Being in crowd
 Being outside of home alone.
 Statistics: decreases among the elderly and
prevalent on women.
 Course of Disorder:
 Onset of Disorder: insidious
Interoceptive avoidance – avoidance of internal physical
sensations. Involve removing oneself from situations or
activities that might produce the physiological arousal that
somehow resembles the beginnings of a panic attack. Most
patients with panic disorder and agoraphobic avoidance.
Specific phobia – is an irrational fear of a specific object or
situation that markedly interferes with an individual’s ability to
function. (e.g., flying, heights, animals, receiving an injection,
seeing blood). The phobic object or situation almost always
provokes immediate fear or anxiety. typically lasting for 6
months or more.
Types of Phobias:
Blood–Injection–Injury Phobia – The average age of onset
for this phobia is approximately 9 years.
Situational Phobias – Phobias characterized by fear of
public transportation or enclosed places l(Claustrophobia).
Natural Environment Phobia – fears of situations or events
occurring in nature. (E.g. heights, storms, and water). these
phobias have a peak age of onset of about 7 years. lasting at
least six months
Animal Phobia – fear of animals or insects. Onset is 7 years.
Separation Anxiety Disorder – characterized by children’s
unrealistic and persistent worry that something will happen to
their parents or other important people in their life or that intimate behavior by showing a willingness to
something will happen to the children themselves that will immediately accompany an unfamiliar adult figure
separate them from their parents (for example, they will be somewhere without first checking back with a
lost, kidnapped, killed, or hurt in an accident). caregiver.
Social Anxiety Disorder (Social Phobia) – Marked fear or Acute Stress Disorder – similar to PTSD but the duration of
anxiety about one or more social situations in which the time period of the disorder is 6 days and only occur within 1
person is exposed to possible scrutiny by others. Examples month and recover within 1 month.
include social interactions (e.g., having a conversation;
OBSESSIVE-COMPULSIVE AND RELATED DISORDER
meeting unfamiliar people), being observed (e.g., eating or
drinking), or performing in front of others (e.g., giving a Obsessive-Compulsive Disorder – client who needs
speech). The individual fears humiliating, embarrassing, lead hospitalization. The obsessions or compulsions are time-
to rejection, or offend others. lasting for 6 months or more. consuming (e.g., take more than 1 hour per day),
Selective Mutism – individuals may fail to speak because of  Obsessions – are recurrent, persistent thoughts,
fear of negative evaluation, but they do not fear negative intrusive and mostly nonsensical thoughts, images,
evaluation in social situations where no speaking is required. or urges that the individual tries to resist or eliminate.
(e.g. nonverbal play)  Compulsions – repetitive behavior, which are the
TRAUMA AND STRESSOR-RELATED DISORDER thoughts or actions used to suppress the obsessions
and provide relief.
Posttraumatic Stress Disorder (PTSD) – emotional
disorders occur after physical assault (particularly rape), car
accidents, natural catastrophes, or the sudden death of a
loved one. When memories occur suddenly, accompanied by
strong emotion, and the victims find themselves reliving the
event, they are having a flashback. Directly experiencing the
traumatic event(s) or Witnessing, in person, the event(s) as
they occurred to others. Persistent in 6 months.
Adjustment disorders – is the development of anxiety or
depression in response to stressful, but not traumatic, life
events. Individuals prone to anxiety or depression generally
may experience increases during stressful life events. Onset
is 3 months
Attachment disorders – Children experiencing inadequate,
abusive, or absent caregiving in early childhood, emerging
before five years of age, in which fail to develop normal
attachment relationships.

 Reactive attachment disorder – the child will very

seldom seek out a caregiver for protection, support,
and nurturance and will seldom respond to offers
from caregivers to provide this kind of care.
emotionally withdrawn and unable to form
attachment with caregivers.
 Disinhibited social engagement disorder – a Body Dysmorphic Disorder – a person who looks normal is
similar set of child rearing circumstances— perhaps obsessively preoccupied with some imagined defect in
including early persistent harsh punishment—would appearance (imagined ugliness). These patients typically
result in a pattern of behavior in which the child have more insight into their problem and may seek out plastic
shows no inhibitions whatsoever to approaching surgery as a remedy. Psychological treatment approaches
adults. Such a child might engage in inappropriately
are also similar to those for OCD and are approximately Causes of Anxiety Disorders
equally successful.
People with anxiety disorders:
 Preoccupation with one or more defects or flaws in
 Feel overwhelming tension, apprehension, or fear
physical appearance that are not observable or
when there is no actual danger.
appear slight to others.
 May take extreme action to avoid the source of their
 At some point during the course of the disorder, the
anxiety
individual has performed repetitive behaviors (e.g.,
mirror checking, excessive grooming, skin picking, Biological Influences
reassurance seeking) or mental acts (e.g.,
comparing his or her appearance with that of others)  Inherited vulnerability to experience anxiety and/or
in response to the appearance concerns. panic attacks
 Activation of specific brain circuits,
Hoarding Disorder – extraordinarily strong emotional neurotransmitters, and neurohormonal systems
attachment to possessions, an exaggerated desire for control
over possessions, and marked deficits in deciding when a Behavioral Influences
possession is worth keeping or not (all possessions are  Marked avoidance of situations and/or people
believed to be equally valuable).
associated with fear, anxiety, or panic attacks
Trichotillomania (Hair Pulling Disorder) – The urge to pull Cognitive and Emotional Influences
out one’s own hair from anywhere on the body, including the
scalp, eyebrows, and arms. This behavior results in  Heightened sensitivity to situations or people
noticeable hair loss, distress, and significant social perceived as threats
impairments  Unconscious feeling that physical symptoms of
panic are catastrophic (intensifies physical reaction)
Excoriation (Skin Picking Disorder) – characterized, as the
label implies, by repetitive and compulsive picking of the skin, Social Influences
leading to tissue damage
 Social support reduces intensity of physical and
Extra: emotional reactions to triggers or stress
Panic and anxiety combine to create different anxiety and  Lack of social support intensifies symptoms
related disorders. Several disorders are grouped under the Treatment for Anxiety Disorder
heading Anxiety Disorders.
Cognitive-Behavioral Therapy
Phobias can be acquired by experiencing some traumatic
event; they can also be learned vicariously or even be taught.  Systematic exposure to anxiety-provoking situations
or thoughts
Posttraumatic stress disorder (PTSD) focuses on avoiding  Learning to substitute positive behaviors and
thoughts or images of past traumatic experiences. thoughts for negative ones
 Learning new coping skills: relaxation exercises,
controlled breathing, etc.
Drug Treatment

 Reduces the symptoms of anxiety disorders by

influencing brain chemistry —antidepressants
(Tofranil, Paxil, Effexor) —benzodiazepines (Xanax,
Klonopin)
Other Treatments

 Managing stress through a healthy lifestyle: rest,

exercise, nutrition, social support, and moderate
alcohol or other drug intake.
 MOOD DISORDERS AND SUICIDE
FUNDAMENTAL STATES OF MOOD DISORDERS
Unipolar Mood Disorders – mood remains at one “pole” of
the usual depression-mania continuum.
Major Depressive Episode – 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. Absence of manic, or hypomanic
episodes
 Depressed mood most of the day, nearly every day
 Markedly diminished interest or pleasure in all, or
almost all, activities most of the day, nearly every
day
 Significant weight loss when not dieting or weight
gain. Note: in children, consider failure to make
expected weight gains.
 Insomnia or hypersomnia nearly every day.
 Psychomotor agitation or retardation nearly every
day
 Fatigue or loss of energy nearly every day
 Feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day
 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
The duration of a major depressive episode, if untreated, is
approximately 4 to 9 months. Most central indicators of a full
major depressive episode are the physical changes
(sometimes called somatic or vegetative symptoms),
emotional shutdown and Anhedonia, loss of energy and
inability to engage in pleasurable activities or have any “fun”
Mania (Manic Episode) – individuals find extreme pleasure
in every activity. Abnormally exaggerated elation, joy, or
euphoria. “persistently increased goal-directed activity or
energy”, hyperactive, flight of ideas.
 Manic episode require a duration of only 1 week,
less if the episode is severe enough to require
hospitalization. Hospitalization could occur, for
example, if the individual was engaging in a self-
destructive
 Irritability, usually near the end.
 being anxious or depressed (dysphoric)
 The duration of an untreated manic episode is
typically 3 to 4 months
 Inflated self-esteem or grandiosity
 Decreased need for sleep
 More talkative than usual or pressure to keep talking
 Distractibility
 Excessive involvement in activities that have a high
potential for painful consequences (e.g. buying
spree)
Hypomanic Episode – a less severe version of a manic
episode that does not cause marked impairment in social or
occupational functioning and need last only 4 days rather
than a full week. Same criteria as the Manic Episode.
THE STRUCTURE OF MOOD DISORDERS
Individuals who experience either depression or mania are
said to suffer from a unipolar mood disorder, because their
mood remains at one “pole” of the usual depression-mania
continuum.
Mixed Features – An individual can experience manic
symptoms but feel somewhat depressed or anxious at the
same time; or be depressed with a few symptoms of mania.
Temporal course – patterns of recurrence and remittance.
Do they tend to recur? If they do:
 Full Remission – Does the patient recover fully for
at least two months between episodes?
 Partial Remission – Do they partially recover
retaining some depressive symptoms?
The importance of temporal course is that they contribute to
decisions on which diagnosis is appropriate. Predicting the
future course of the disorder, as well as in choosing
appropriate treatments.
Onset
 Early onset: If onset is before age 21 years.
 Late onset: If onset is at age 21 years or older.
Severity – based on the number of criterion symptoms, the
severity of those symptoms, and the degree of functional
disability.
 Mild: Few, if any, symptoms in excess of those
required to make the diagnosis are present, the
intensity of the symptoms is distressing but
 manageable, and the symptoms result in minor
impairment in social or occupational functioning.
 Moderate: The number of symptoms, intensity of
symptoms, and/or functional impairment are
between those specified for “mild” and “severe.”
 Severe: The number of symptoms is substantially in
excess of that required to make the diagnosis, the
intensity of the symptoms is seriously distressing
and unmanageable, and the symptoms markedly
interfere with social and occupational functioning.
Configurations of Depression
 “with pure dysthymic syndrome,” – one has not
met criteria for a major depressive episode in at least
the preceding two years.
 “with persistent major depressive episode,” –
presence of a major depressive episode over at least
a two-year period
 “with intermittent major depressive episodes,” –
double depression
 “With intermittent major depressive episodes
with current episode” – Full criteria for a major
depressive episode are currently met, but there have
been periods of at least 8 weeks in at least the
preceding 2 years with symptoms below the
threshold for a full major depressive episode.
 “With intermittent major depressive episodes,
without current episode” – Full criteria for a major
depressive episode are not currently met, but there
has been one or more major depressive episodes in
at least the preceding 2 years.
Specifiers – describe depressive disorders. Symptoms may
or may not accompany a depressive disorder; when they do,
they are often helpful in determining the most effective
treatment or likely course.
Psychotic features – hallucinations, delusions, somatic
(physical) delusions, believing, for example, that their bodies
are rotting internally and auditory hallucinations.
 Mood Congruent – hallucination and delusion
directly related to the depression.
 Mood-incongruent – types of hallucinations or
delusions such as delusions of grandeur that do not
seem consistent with the depressed mood.
 Conditions in which psychotic symptoms
accompany depressive episodes are relatively rare.
Anxious distress – presence and severity of accompanying
anxiety. Indicates a more severe condition, makes suicidal
thoughts and completed suicide more likely, and predicts a
poorer outcome from treatment. (comorbid or not).
Mixed features – several (at least three) symptoms of mania
or major depressive episodes both within major depressive
disorder and persistent depressive disorder.
Melancholic features – applies only if the full criteria for a
major depressive episode have been met. Severe somatic
(physical) symptoms, such as early-morning awakenings,
weight loss, and anhedonia.
Catatonic features – absence of movement (a stuporous
state) or catalepsy. Also involve excessive but random or
purposeless movement.
Atypical features – most people with depression sleep less
and lose their appetite, individuals with this specifier
consistently oversleep and overeat during their depression
and therefore gain weight.
Peripartum onset – period of time just before and just after
the birth (postpartum).
 Baby blues – minor adjustment in childbirth where
new mothers may be tearful and have some
temporary mood swings, but these are normal
responses to the stresses of childbirth and
disappear quickly. (not applicable in Peri Onset)
 Peripartum Depression – difficulty understanding
why a mother is depressed, because they assume
this is a joyous time.
Seasonal pattern – applies to recurrent major depressive
disorder (and also to bipolar disorders). Accompanies
episodes that occur during certain seasons.
 Depressive Episode = ↑ late fall, ↓ Spring
 Bipolar Disorder = Depressed: Winter, Manic:
Summer.
 Seasonal affective disorder (SAD) – episodes
must have occurred for at least two years with no
evidence of nonseasonal major depressive episodes
occurring during that period of time.
Rapid-Cycling – applicable only in Bipolar Disorders. People
move quickly in and out of depressive or manic episodes. An
individual with bipolar disorder who experiences at least four
manic or depressive episodes within a year is considered to
have a rapid-cycling pattern.
 Rapid (mood) switching – direct transition from
one mood state to another happens. It is a
treatment-resistant form of the disorder.
Specify the clinical status and/or features of the current or
most recent major depressive episode:
Single episode or recurrent episode
Mild, moderate, severe
With anxious distress
With mixed features
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia
With peripartum onset
With seasonal pattern (recurrent episode only) In partial
remission, in full remission
DEPRESSIVE DISORDERS – two factors that most
importantly describe mood disorders are severity and
chronicity.
 Recurrence – If two or more major depressive
episodes occurred and were separated by at least 2
months during which the individual was not
depressed.
Major Depressive Disorder – At least one major depressive
episode. There has never been a manic episode or
hypomanic episode.
Persistent depressive disorder (dysthymia) – shares
many of the symptoms of major depressive disorder but
differs in course. But depression remains relatively
unchanged over long periods, sometimes 20 or 30 years or
more
 Continues at least 2 years, during which the patient
cannot be symptom free for more than 2 months at
a time. Note: In children and adolescents, mood can
be irritable and duration must be at least 1 year
 During the 2-year period (1 year for children or
adolescents) of the disturbance, the person has
never been without the symptoms in criteria for
more than 2 months at a time.
 Presence, while depressed, of two (or more) of the
following: Poor appetite or overeating, Insomnia or
hypersomnia, Low energy or fatigue, Low self-
esteem, Poor concentration or difficulty making
decisions, and Feelings of hopelessness.
 Higher rates of comorbidity and slower rate of
improvement over time
 Less or fewer number of symptoms required/shown
 Dysthymia – people suffering from mild persistent
depression with fewer symptoms.
Double depression – individuals who suffer from both major
depressive episodes and persistent depression with fewer
symptoms. Develop few depressive symptoms at early age
and will occur later and revert to major depressive episode.
Which will lead to severe psychopathology and a problematic
future course.
Onset and Duration
 Developing major depression is fairly low until the
early teens, when it begins to rise in a steady (linear)
fashion.
 Mean age of onset for major depressive disorder is
30 years.
 Children ages 5 to 12, 5% had experienced major
depressive disorder. The corresponding figures in
adolescence (ages 13 to 17) was 19%; in emerging
adulthood (ages 18 to 23), 24%; and in young
adulthood (ages 24 to 30) 16%.
 Typical duration of the first episode being 2 to 9
months if untreated
Premenstrual Dysphoric Disorder (PMDD) – combination
of physical symptoms, irritability, anger, severe mood swings
and anxiety are associated with incapacitation during this
period of time. Criteria must have been met for most
menstrual cycles that occurred in the preceding year.
 Decreased interest in usual activities (e.g., work,
school, friends, hobbies).
 Subjective difficulty in concentration.
 Lethargy, easy fatigability, or marked lack of energy.
 Marked change in appetite; overeating; or specific
food cravings.
 Hypersomnia or insomnia.
 A sense of being overwhelmed or out of control.
 Physical symptoms such as breast tenderness or
swelling, joint or muscle pain, a sensation of
“bloating”, or weight gain.
Disruptive Mood Dysregulation Disorder – Severe
recurrent temper outburst manifested verbally (e.g., verbal
rages) and/or behaviorally (e.g., physical aggression toward
people or property) that are grossly out of proportion in
intensity or duration to the situation or provocation.
 The temper outbursts are inconsistent with
developmental level. The temper outbursts occur, on
average, three or more times per week.
 The mood between temper outbursts is persistently
irritable or angry most of the day, nearly every day,
 and is observable by others (e.g., parents, teachers,
peers).
 Criteria have been present for 12 or more months.
Throughout that time, the individual has not had a
period lasting 3 or more consecutive months without
all of the symptoms.
 Criteria are present in at least two of three settings
(i.e., at home, at school, with peers) and are severe
in at least one of these.
 The diagnosis should not be made for the first time
before age 6 years or after age 18 years.
 By history or observation, the age at onset of Criteria
is before 10 years.
 There has never been a distinct period lasting more
than 1 day during which the full symptom criteria,
except duration, for a manic or hypomanic episode
have been met.
BIPOLAR DISORDER – tendency of manic episodes to
alternate with major depressive episodes in an unending
roller-coaster ride from the peaks of elation to the depths of
despair.
Bipolar I – major depressive episodes alternate with full
manic episodes. There must be a symptom-free period of at
least 2 months between them. Criteria have been met for at
least one manic episode.
Bipolar II – at least one major depressive episode alternate
with at least one hypomanic episode. There has never been
a manic episode.
Cyclothymic disorder – chronic alternation of mood
elevation and depression that does not reach the severity of
manic or major depressive episodes.
 Tend to be in one mood state or the other for years
with relatively few periods of neutral (or euthymic)
mood.
 This pattern must last for at least 2 years (1 year for
children and adolescents) to meet criteria for the
disorder. 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.
 Alternate between the kinds of mild depressive
symptoms
 Criteria for a major depressive, manic, or hypomanic
episode have never been met.
Onset and Duration
 The average age of onset for bipolar I disorder is
from 15 to 18 and for bipolar II disorder from 19 and
22, although cases of both can begin in childhood
 Bipolar disorders begin more acutely; suddenly.
 Cyclothymia is chronic and lifelong
A grief to Depression – Approximately 20% of bereaved
individuals may experience a complicated grief reaction in
which the normal grief response develops into a full-blown
mood disorder.
Suicide
 Suicide is often associated with mood disorders but
can occur in their absence or in the presence of
other disorders. It is the 11th leading cause of death
among all people in the United States, but among
adolescents, it is the 3rd leading cause of death.
 In understanding suicidal behavior, three indices are
important: suicidal ideation (serious thoughts about
committing suicide), suicidal plans (a detailed
method for killing oneself), and suicidal attempts
(that are not successful). Important, too, in learning
about risk factors for suicides is the psychological
autopsy, in which the psychological profile of an
individual who has committed suicide is
reconstructed and examined for clues.
Causes of Mood Disorders
People with mood disorders experience one or both of the
following:
 Mania: A frantic “high” with extreme overconfidence
and energy, often leading to reckless behavior
 Depression: A devastating “low” with extreme lack
of energy, interest, confidence, and enjoyment of
life.
Biological Influences
 Inherited vulnerability
 Altered neurotransmitters and neurohormonal
systems
 Sleep deprivation
 Circadian rhythm disturbances
Behavioral Influences
 Depression – General slowing down, neglect of
responsibilities and appearance, irritability;
complaints about matters that used to be taken in
stride
  Mania – Hyperactivity, Reckless or otherwise
unusual behavior.
Emotional and Cognitive Influences
 Depression – Emotional flatness or emptiness ,
inability to feel pleasure, poor memory, inability to
concentrate, hopelessness and/or learned
helplessness, loss of sexual desire, loss of warm
feelings for family and friends, exaggerated self-
blame or guilt, overgeneralization, loss of self-
esteem, suicidal thoughts or actions
 Mania – exaggerated feelings of euphoria and
excitement
Social Influences
 Women and minorities—social inequality and
oppression and a diminished sense of control
 Social support can reduce symptoms
 Lack of social support can aggravate symptoms
Trigger
 Negative or positive life changes (death of a loved
one, promotion, etc.)
 Physical illness
Treatment of Mood Disorders – is most effective and
easiest when it’s started early. Most people are treated with
a combination of these methods.
Medications – antidepressants can help to control
symptoms and restore neurotransmitter functioning.
 Tricyclics (Tofranil, Elavil)
 Monamine oxidase inhibitors (MAO inhibitors):
(Nardil, Parnate); MAO inhibitors can have severe
side effects, especially when combined with certain
foods or over-the-counter medications
 Selective-serotonin reuptake inhibitors or SSRIs
(Prozac, Zoloft) are newer and cause fewer side
effects than tricyclics or MAO inhibitors
 Lithium is the preferred drug for bipolar disorder;
side effects can be serious; and dosage must be
carefully regulated
Cognitive-Behavioral Therapy – learn to replace negative
depressive thoughts and attributions with more positive ones
and develop more effective coping.
Interpersonal Psychotherapy – focus on the social and
interpersonal triggers for their depression (such as the loss
of a loved one) and develop skills to resolve interpersonal
conflicts and build new relationships.
Electroconvulsive Therapy – for severe depression, ECT is
used when other treatments have been ineffective. It usually
has temporary side effects, such as memory loss and
lethargy. In some patients, certain intellectual and/or memory
functions may be permanently lost.
Light Therapy – For seasonal affective disorder.
OTHER MOOD DISORDERS
Substance/Medication-Induced Depressive Disorder –
depressive symptoms with evidence from the history,
physical examination, or laboratory findings of both:
 The symptoms in Criteria 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 Criteria.
The symptoms persist for a substantial period of time (e.g.,
about 1 month) after the cessation of acute withdrawal or
severe intoxication.
Depressive Disorder Due to Another Medical Condition –
depressive symptoms with evidence from the history,
physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of
another medical condition.
Other specified Depressive Disorder without meeting the
full criteria:
Recurrent brief depression: Concurrent presence of
depressed mood and at least four other symptoms of
depression for 2-13 days at least once per month.
Short-duration depressive episode (4-13 days):
Depressed affect and at least four of the other eight
symptoms of a major depressive episode
Depressive episode with insufficient symptoms:
Depressed affect and at least one of the other eight
symptoms of a major depressive episode for at least 2 weeks.
SOMATIC SYMPTOMS AND RELATED DISORDER AND
DISSOCIATIVE DISORDERS
Both are relatively rare and not well understood.
Somatic symptom disorders – preoccupation with an
individual’s health or appearance becomes so great that it
dominates their lives. Exaggerates the slightest physical
symptom. Soma means body.
 Grouped under “medically unexplained physical
symptoms”.
Dissociative disorders – dissociation or dissociative
experiences; people experience alterations, or detachments,
in consciousness or identity. (“This isn’t really me,” or “That
doesn’t really look like my hand,” or “There’s something
unreal about this place.”)
 These experiences are so intense and extreme that
they lose their identity entirely and assume a new
one or they lose their memory or sense of reality and
are unable to function.
“Hysterical neurosis.” – Somatic symptom and dissociative
disorders are strongly linked historically and share common
features.
FIVE BASIC SOMATIC SYMPTOMS
1. Somatic Symptom Disorder [300.82 (F45.1)] – known
before as Briquet’s syndrome. People with somatic
symptom disorder do not always feel the urgency to take
action but continually feel weak and ill, and they avoid
exercising, thinking it will make them worse. One or more
physical symptoms are relatively severe and are associated
with anxiety and distress
 Physical symptoms – pain, breathlessness,
headache and paralysis, etc.
Diagnostic Criteria for Somatic Symptom Disorder
 One or more somatic symptoms that are distressing
and/or result in significant disruption of daily life.
 Excessive thoughts, feelings, and behaviors related
to the somatic symptoms or associated health
concerns as manifested by at least one of the
following:
 Disproportionate and persistent thoughts
about the seriousness of one’s symptoms.
 High level of health-related anxiety.
 Excessive time and energy devoted to
these symptoms or health concerns.
 Although any one symptom may not be
continuously present, the state of being
symptomatic is persistent (typically more than 6
months).
 Specify if: With predominant pain (previously pain
disorder): This specifier is for individuals whose
somatic complaints predominantly involve pain.
 Specify current severity:
 Mild: Only one of the symptoms in Criteria
is fulfilled.
 Moderate: Two or more of the symptoms
specified.
 Severe: Two or more of the symptoms are
fulfilled, plus there are multiple somatic
complaints (or one very severe somatic
symptom).
2. Illness Anxiety Disorder [300.7 (F45.21)] – formerly
known as “hypochondriasis,”. Preoccupation with fears of
having or acquiring a serious illness. More worried on the
idea that an individual was either ill or developing an illness
than the specific physical symptoms.
 Some examples: Public restrooms and, on occasion,
public telephones were feared as sources of
infection. Headache indicated a brain tumor and
breathlessness was an impending heart attack.
 Somatic symptoms are not present or, if present, are
only mild in intensity.
 There is a high level of anxiety about health, and
the individual is easily alarmed about personal
health status.
 The individual performs excessive health-related
behaviors. (e.g. regularly check for sign of illness)
 Illness preoccupation has been present for at least 6
months, but the specific illness that is feared may
change over that period of time.
 Specify whether:
 Care-seeking type: Medical care,
including physician visits or undergoing
tests and procedures, is frequently used.
 Care-avoidant type: Medical care is rarely
used.
Somatic symptom disorder and illness anxiety disorder are
characterized by anxiety or fear that one has a serious
disease but it differ from anxiety disorders because the
individual is preoccupied with bodily symptoms.
  “disease conviction” – difficult-to-shake belief
where individuals mistakenly believe they have a
disease.
 These disorders are spread fairly evenly across
various phases of adulthood.
 Somatic symptom disorders are chronic, often
continuing into old age.
Culture-specific syndromes seem to fit comfortably with
somatic symptom disorders.
 Koro – Chinese belief that severe anxiety and
sometimes panic, that the genitals are retracting into
the abdomen. (mostly males)
 Dhat – Indian belief that they are losing semen,
something that obviously occurs during sexual
activity that results to dizziness, weakness, and
fatigue.
 Other culture-specific syndrome: Africa – hot
sensations in the head or a sensation of something
crawling in the head.
 Pakistan and India – sensation of burning in the
hands and feet.
3. Conversion Disorder (Functional Neurological
Symptom Disorder) – Freud popularized that anxiety
resulting from unconscious conflicts somehow was
“converted” into physical symptoms to find expression. The
ICD-9-CM code for conversion disorder is 300.11
 “Functional” refers to a symptom without an
organic cause.
 Physical malfunctioning, such as paralysis,
blindness, or difficulty speaking (aphonia), without
any physical or organic pathology to account for the
malfunction.
 Somebody going blind when all visual processes are
normal or experiencing paralysis of the arms or legs
when there is no neurological damage.
Diagnostic Criteria for Conversion Disorder
 One or more symptoms of altered voluntary motor
or sensory function.
 Clinical findings provide evidence of incompatibility
between the symptom and recognized neurological
or medical conditions.
 The symptom or deficit is not better explained by
another medical or mental disorder.
 The symptom or deficit causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning or warrants
medical evaluation.
Astasia-abasia – walking began to deteriorate, including
weakness in legs and difficulty keeping balance, with the
result that an individual fell often. Until they cannot walk
anymore.
Psychogenic non-epileptic seizures – people have
seizures, which may be psychological in origin, because
no significant electroencephalogram (EEG) changes can
be documented.
Globus hystericus – sensation of a lump in the throat
that makes it difficult to swallow, eat, or sometimes talk.
Distinguishing among conversion reactions, real physical
disorders, and outright malingering (faking) is sometimes
difficult.
 La belle indifference – patients with
conversion reactions had the same quality of
indifference to the symptoms thought to be
present in some people with severe somatic
symptom disorder. (later on, debunked)
 People with conversion symptoms can usually
function normally, they seem truly unaware
either of this ability or of sensory input. (e.g.
blindness can usually avoid objects in their
visual field, but they will tell you they can’t see
the objects.)
Conversion disorder comorbid anxiety and mood disorders
are also common and are relatively rare in mental health
settings but remember that people who seek help for this
condition are more likely to consult neurologists or other
specialists.
 Like severe somatic symptom disorder, conversion
disorders are found primarily in women. Typically
develop during adolescence or slightly thereafter.
 Conversion symptoms often disappear after a time,
only to return later in the same or similar form when
a new stressor occurs
4. Factitious disorders – fall somewhere between
malingering and conversion disorders. Symptoms are under
voluntary control, as with malingering, but there is no obvious
reason for voluntarily producing the symptoms except,
possibly, to assume the sick role and receive increased
attention.
 Factitious disorder imposed on another –
formerly known as Munchausen syndrome by proxy.
 Individual deliberately makes someone else sick.
(e.g. mother injecting her own urine into the child’s
intravenous line so that she could take care of him.)
 True nature of the illness is most often unsuspected
and the people perceive the parents as remarkably
caring, cooperative, and involved in providing for
their child’s well-being.
 Video surveillance was the method used to establish
the diagnosis and separating parent and child.
Diagnostic Criteria for Factitious Disorder
 Falsification of physical or psychological signs or
symptoms, or induction of injury or disease,
associated with identified deception.
 The individual presents himself or herself to others
as ill, impaired or injured.
 The deceptive behavior is evident even in the
absence of obvious external rewards.
 The behavior is not better accounted for by another
mental disorder such as delusional belief system or
acute psychosis
5. Psychological Factors Affecting Other Medical
Conditions – presence of a diagnosed medical condition
such as asthma, diabetes, or severe pain clearly caused by
a known medical condition such as cancer that is adversely
affected (increased in frequency or severity) by one or more
psychological or behavioral factors.
 A medical symptom or condition (other than a mental
disorder) is present.
 Psychological or behavioral factors adversely affect
the medical condition in one of the following ways:
 The factors have influenced the course of
the medical condition as shown by a close
temporal association between the
psychological factors and the development
or exacerbation of, or delayed recovery
from, the medical condition.
 The factors interfere with the treatment of
the medical condition (e.g., poor
adherence).
 The factors constitute additional well-
established health risks for the individual.
 The factors influence the underlying
pathophysiology, precipitating or
exacerbating symptoms or necessitating
medical attention.
Other Specified Somatic Symptom and Related Disorder
(did not meet the full criteria).
 Brief somatic symptom disorder: Duration of
symptoms is less than 6 months.
 Brief illness anxiety disorder: Duration of
symptoms is less than 6 months.
 Illness anxiety disorder without excessive
health-related behaviors: Criteria for illness
anxiety disorder is not met.
 Pseudocyesis: A false belief of being pregnant that
is associated with objective signs and reported
symptoms of pregnancy.
DISSOCIATIVE DISORDERS – trigger from extremely
stressful event, such as an accident; trauma and sleep
deprivation. One “dissociates” from reality.
Depersonalization – perception alters so that you
temporarily lose the sense of your own reality, as if you were
in a dream and you were watching yourself.
 Things around them seemed unreal or dreamlike
and they felt time had stopped. They also felt
estranged from other people and distant from their
own emotions; a number of them felt they were
strangers to themselves.
Derealization – your sense of the reality of the external world
is lost. Things may seem to change shape or size; people
may seem dead or mechanical.
Disintegrated experiences – Cannot remember why we are
in a certain place or even who we are. Lose our sense that
our surroundings are real. Finally, begin thinking we are
somebody else—somebody who has a different personality,
different memories, and even different physical reactions,
such as allergies we never had.
Depersonalization-Derealization Disorder [300.6 (F48.1)]
– When feelings of unreality are so severe and frightening
that they dominate an individual’s life and prevent normal
functioning.
 The presence of persistent or recurrent primary
experiences of depersonalization, derealization, or
both.
 During the depersonalization or derealization
experience, reality testing remains intact.
 This disorder approximately equally split between
men and women.
 Mean age of onset was 16 years, and the course
tended to be chronic.
 Anxiety, mood, and personality disorders are also
commonly found in these individuals.
  “tunnel vision” (perceptual distortions) and “mind
emptiness” (difficulty absorbing new information)
 Other symptoms: Looking at the world through a
fog, did not hear part of conversation, finding familiar
place strange and unfamiliar, staring off into space;
unaware of time, can’t remember if just did
something or thought it, do usually difficult things
with ease/ spontaneity, act so differently/feel like two
different people and talk out loud to oneself when
alone.
Dissociative Amnesia [300.12 (F44.0)] – severe
dissociative disorders where there is an inability to recall
important autobiographical information, usually of a traumatic
or stressful nature, that is inconsistent with ordinary
forgetting.
 Generalized Amnesia – People who are
unable to remember anything, including who
they are. Lifelong or may extend from a period
in the more recent past, such as 6 months or a
year previously
 Localized or Selective Amnesia – a failure to
recall specific events, usually traumatic, that
occur during a specific period.
 Specify if: With dissociative fugue: Apparently
purposeful travel or bewildered wandering that
is associated with amnesia for identity or for
other important autobiographical information.
 Dissociative amnesia is common during war
Dissociative Fugue (flight) [300.13 (F44.1)] – memory loss
revolves around a specific incident—an unexpected trip (or
trips). Mostly, individuals just take off and later find
themselves in a new place, unable to remember why or how
they got there.
Dissociative Trance – Sudden changes in personality
accompany a trance or “possession”. Often associated with
stress or trauma. Prevalent worldwide, usually in a religious
context; rarely seen in Western cultures. More common in
women than in men.
Dissociative amnesia seldom appears before adolescence
and usually occurs in adulthood. Dissociative amnesia is the
most prevalent of all the dissociative disorders
Running disorders seem to resemble dissociative fugue:
 Amok – Western culture belief that individuals in this
trancelike state often brutally assault and sometimes
kill people or animals. If the person is not killed
himself, he probably will not remember the episode.
(mostly males)
 Running Amok – individual enters a trancelike state
and suddenly, imbued with a mysterious source of
energy, runs or flees for a long time. (prevalent in
women)
 Pivloktoq – running amok term for Arctic Natives
 Frenzy witchcraft – Navajo tribes’ term for running
amok
Dissociative Identity Disorder [300.14 (F44.81)] – may
adopt as many as 100 new identities, all simultaneously
coexisting, although the average number is closer to 15. In
some cases, the identities are complete, each with its own
behavior, tone of voice, and physical gestures. But in many
cases, only a few characteristics are distinct, because the
identities are only partially independent, so it is not true that
there are “multiple” complete personalities.
 Alters – generally seemed to be another person
entirely or separate identities.
 “host” identity – The person who becomes the
patient and asks for treatment. Attempt to hold
various fragments of identity together but end up
being overwhelmed. The original personality.
 Switch – transition from one personality to another,
instantaneously.
Diagnostic Criteria for Dissociative Identity Disorder
 Disruption of identity characterized by two or more
distinct personality states, which may be described
in some cultures as an experience of possession.
The disruption of marked discontinuity in sense of
self and sense of agency, accompanied by related
alterations in affect, behavior, consciousness,
memory, perception, cognition, and/or sensory-
motor functioning. These signs and symptoms may
be observed by others or reported by the individual.
 Recurrent gaps in the recall of everyday events,
important personal information, and/or traumatic
events that are inconsistent with ordinary forgetting.
 The disturbance is not a normal part of a broadly
accepted cultural or religious practice. Note: In
children, the symptoms are not attributable to
imaginary playmates or other fantasy play.
Statistics
 Of people with DID, the ratio of females to males is
as high as 9:1.
  The onset is almost always in childhood, often as
young as 4 years of age, although it is usually
approximately 7 years after the appearance of
symptoms before the disorder is identified.
 A large percentage of DID patients have
simultaneous psychological disorders that may
include anxiety, substance abuse, depression, and
personality disorders.
 The causes of somatic symptom disorders are not
well understood but seem closely related to anxiety
disorders.
Other Specified Dissociative Disorder (did not meet full
criteria or any of dissociative disorder) [300.15 (F44.89)]
Chronic and recurrent syndromes of mixed dissociative
symptoms: This category includes identity disturbance
associated with less-than-marked discontinuities in sense of
self and agency, or alterations of identity or episodes of
possession in an individual who reports no dissociative
amnesia.
Identity disturbance due to prolonged and intense
coercive persuasion: Individuals who have been subjected
to intense coercive persuasion (e.g., brainwashing, thought
reform, indoctrination while captive, torture, long-term
political imprisonment, recruitment by sects/cults or by terror
organizations) may present with prolonged changes in, or
conscious questioning of, their identity.
Acute dissociative reactions to stressful events: This
category is for acute, transient conditions that typically last
less than 1 month, and sometimes only a few hours or days.
These conditions are characterized by constriction of
consciousness; depersonalization; derealization; perceptual
disturbances (e.g., time slowing, macropsia); micro-
amnesias; transient stupor; and/or alterations in sensory-
motor functioning (e.g., analgesia, paralysis).
Dissociative trance: This condition is characterized by an
acute narrowing or complete loss of awareness of immediate
surroundings that manifests as profound unresponsiveness
or insensitivity to environmental stimuli. The
unresponsiveness may be accompanied by minor
stereotyped behaviors (e.g., finger movements) of which the
individual is unaware and/or that he or she cannot control, as
well as transient paralysis or loss of consciousness. The
dissociative trance is not a normal part of a broadly accepted
collective cultural or religious practice.
 EATING, FEEDING AND SLEEP-WAKE DISORDERS
Psychological disruptions of two of our relatively
automatic behaviors, eating and sleeping, which
substantially affect the rest of our behavior.
MAJOR TYPES OF EATING DISORDER – the chief
characteristic of these related disorders is an overwhelming,
all-encompassing drive to be thin.
 More than 90% of the severe cases are young
females who live in a socially competitive
environment.
 The strongest contributions to etiology of this
disorder seem to be sociocultural
 Obesity – The more overweight someone is at a
given height, the greater the risks to health.
Produced by the consumption of a greater number
of calories than are expended in energy
Bulimia Nervosa [307.51 (F50.2)] – out-of-control eating
episodes, or binges, are followed by self-induced vomiting,
excessive use of laxatives, or other attempts to purge (get rid
of) the food.
 Typically, they eat more junk food than fruits and
vegetables—than most people would eat under
similar circumstances.
 Purging techniques – individual attempts to
compensate for the binge eating and potential
weight gain. (e.g. self-induced vomiting immediately
after eating).
 Purging Type – vomiting, laxatives, or
diuretics.
 Nonpurging Type – excessive exercise
and/or fasting.
Diagnostic Criteria for Bulimia Nervosa
 Recurrent episodes of binge eating; eating, in a
discrete period of time (e.g., within any 2-hour
period) and a sense of lack of control overeating
during the episode (e.g., a feeling that one cannot
stop eating or control what or how much one is
eating)
 Recurrent inappropriate compensatory behavior in
order to prevent weight gain
 The binge eating and inappropriate compensatory
behaviors both occur, on average, at least once a
week for 3 months.
 Self-evaluation is unduly influenced by body shape
and weight.
 The disturbance does not occur exclusively during
episodes of anorexia nervosa.
Medical Consequences
 Salivary gland enlargement – repeated vomiting
result to puff cheeks.
 Electrolyte Imbalance – continued vomiting may
upset the chemical balance of bodily fluids, including
sodium and potassium levels.
 Cardiac arrhythmia (disrupted heartbeat), seizures,
and renal (kidney) failure.
 Calluses on their fingers or the backs of their hands
caused by the friction of contact with the teeth and
throat.
 Associated with anxiety and mood disorders.
Anorexia nervosa [307.1] – the person eats nothing beyond
minimal amounts of food, so body weight sometimes drops
dangerously.
 Literally means a “nervous loss of appetite”—an
incorrect definition because appetite often remains
healthy.
 People with anorexia are proud of both their diets
and their extraordinary control. People with bulimia
are ashamed of both their eating issues and their
lack of control
 Anorexia have an intense fear of obesity and
relentlessly pursue thinness
 has the highest mortality rate of any psychological
disorder reviewed in this book, including depression.
 Significantly low weight – defined as a weight that
is less than minimally normal or, for children and
adolescents, less than that minimally expected.
Two subtypes of anorexia nervosa – subtyping refer only
to the last 3 months.
 Restricting type – individuals’ diet to limit calorie
intake. Not engaged in recurrent episodes of binge
eating or purging behavior.
 Binge-eating–purging type – they rely on purging.
Has engaged in recurrent episodes of binge eating
or purging behavior
Diagnostic Criteria for Anorexia Nervosa
 Restriction of energy intake relative to requirements,
leading to a significantly low body weight in the
context of age, sex, developmental trajectory, and
physical health.
  Intense fear of gaining weight or of becoming fat, or
persistent behavior that interferes with weight gain,
even though at a significantly low weight.
 Disturbance in the way in which one’s body weight
or shape is experienced, undue influence of body
weight or shape on self-evaluation, or persistent lack
of recognition of the seriousness of the current low
body weight.
Medical Consequences
 Cessation of menstruation (amenorrhea)
 Lanugo – downy hair on the limbs and cheeks.
 dry skin, brittle hair or nails, and sensitivity to or
intolerance of cold temperatures
 Anxiety disorders and mood disorders are often
present in individuals with anorexia and Substance
abuse.
Binge-eating disorder [307.51 (F50.8)] – individuals may
binge repeatedly and find it distressing, but they do not
attempt to purge the food.
 Same first previous criteria in the Bulimia.
 The binge-eating episodes are associated with three
(or more) of the following:
 Eating much more rapidly than normal
 Eating until feeling uncomfortably full.
 Eating large amounts of food when not
feeling physically hungry.
 Eating alone because of feeling
embarrassed by how much one is eating.
 Feeling disgusted with oneself, depressed,
or very guilty afterward.
 Marked distress regarding binge eating is present
 The binge eating occurs, on average, at least once
a week for 3 months
Bulimia Nervosa, Anorexia Nervosa and BED share the same
criteria and specifier:
Specify if:
 In partial remission: After full criteria for binge-
eating disorder were previously met, *the disorder
occurs at an average frequency of less than one
episode per week for a sustained period of time.
 In full remission: After full criteria for *the disorder
disorder were previously met, none of the criteria
have been met for a sustained period of time.
Specify current severity (in Bulimia and Binge-eating):
The minimum level of severity is based on the frequency of
episodes of *this disorder. The level of severity may be
increased to reflect other symptoms and the degree of
functional disability.
 Mild: 1-3 episodes per week.
 Moderate: 4-7 episodes per week.
 Severe: 8-13 episodes per week.
 Extreme: 14 or more episodes per week
Specify current severity in Anorexia Nervosa
 Mild: BMI>17kg/m
 Moderate: BM116-16.99 kg/m^
 Severe: BM115-15.99 kg/m^
 Extreme: BMI < 15 kg/m
Statistics
 Majority of individuals with bulimia are women.
Adolescent girls are most at risk
 Many cases of anorexia and BED, but not bulimia,
begin after age 18.
 The median age of onset for all eating-related
disorders occurred in a narrow range of 18 to 21
years.
 For anorexia, this age of onset was fairly consistent,
with younger cases tending to begin at age 15
 It was more common for cases of bulimia to begin as
early as age 10
 Bulimia tends to be chronic if untreated.
Pica [307.52] [(F98.3) – child] [(F50.8) – adults] –
Persistent eating of nonnutritive, nonfood substances over a
period of at least 1 month. The eating of nonnutritive, nonfood
substances is inappropriate to the developmental level of the
individual. The eating behavior is not part of a culturally
supported or socially normative practice.
Rumination Disorder [307.53 (F98.21)] – Repeated
regurgitation of food over a period of at least 1 month.
Regurgitated food may be re-chewed, re-swallowed, or spit
out.
Avoidant/Restrictive Food Intake Disorder [307.59
(F50.8)] – An eating or feeding disturbance (e.g., apparent
lack of interest in eating or food; avoidance based on the
sensory characteristic of food; concern about aversive
consequences of eating) as manifested by persistent failure
to meet appropriate nutritional and/or energy needs.
 Significant weight loss (or failure to achieve
expected weight gain or faltering growth in children).
 Significant nutritional deficiency.
  Dependence on enteral feeding or oral nutritional
supplements.
 Marked interference with psychosocial functioning.
SLEEP-WAKE DISORDERS – interrupts sleep
Dyssomnia – involve difficulties in getting enough sleep,
problems with sleeping when you want to (not being able to
fall asleep until 2 a.m. when you have a 9 a.m. class), and
complaints about the quality of sleep, such as not feeling
refreshed even though you have slept the whole night.
Parasomnia – characterized by abnormal behavioral or
physiological events that occur during sleep, such as
nightmares and sleepwalking.
ASSESSMENT OF SLEEP
Polysomnographic (PSG) evaluation – evaluation
assesses an individual’s sleep habits with various electronic
tests to measure airflow, brain activity, eye movements,
muscle movements, and heart activity. Results are weighed
with a measure of sleep efficiency (SE), the percentage of
time spent asleep.
Actigraph – records the number of arm movements, and the
data can be downloaded into a computer to determine the
length and quality of sleep.
Sleep efficiency (SE) – percentage of time actually spent
asleep. To know the average number of hours the individual
sleeps each day.
 SE of 100% – would mean you fall asleep as soon
as your head hits the pillow and do not wake up
during the night.
 SE of 50% – would mean half your time in bed is
spent trying to fall asleep; that is, you are awake half
the time.
Daytime sequelae – determine whether a person has a
problem with sleep; behavior while awake.
DYSSOMNIA – Disturbances in the timing, amount, or quality
of sleep.
Insomnia Disorder [780.52 (G47.00)] – Difficulty falling
asleep at bedtime, problems staying asleep throughout the
night, or sleep that does not result in the person feeling
rested even after normal amounts of sleep.
 Microsleeps – a sleep that last several seconds or
longer.
 Insomnia means “not sleeping,”
 Primary insomnia – sleep problems were not
related to other medical or psychiatric problems.
Diagnostic Criteria for Insomnia Disorder
 A predominant complaint of dissatisfaction with
sleep quantity or quality
 Difficulty initiating sleep
 Difficulty maintaining sleep, characterized
by frequent awakenings or problems
returning to sleep after awakenings.
 Note: In children, this may manifest as
difficulty initiating sleep without caregiver
intervention.
 The sleep difficulty occurs at least 3 nights per week.
 The sleep difficulty is present for at least 3 months.
 The sleep difficulty occurs despite adequate
opportunity for sleep.
 Coexisting mental disorders and medical conditions
do not adequately explain the predominant
complaint of insomnia.
 Specify if:
 Episodic: Symptoms last at least 1 month
but less than 3 months.
 Persistent: Symptoms last 3 months or
longer.
 Recurrent: Two (or more) episodes within
the space of 1 year.
Hypersomnolence Disorders [780.54 (G47.10)] – involve
sleeping too much (hyper means “in great amount” or
“abnormal excess”). Excessive sleepiness that is displayed
as either sleeping longer than is typical or frequent falling
asleep during the day.
 Self-reported excessive sleepiness
(hypersomnolence) despite a main sleep period
lasting at least 7 hours, with at least one of the
following symptoms:
 Recurrent periods of sleep or lapses into
sleep within the same day.
 A prolonged main sleep episode of more
than 9 hours per day that is non-restorative
(i.e., unrefreshing).
 Difficulty being fully awake after abrupt
awakening
 The hypersomnolence occurs at least three times
per week, for at least 3 months.
 Coexisting mental and medical disorders do not
adequately explain the predominance complaint of
hypersomnolence.
  Specify if:
 Acute: Duration of less than 1 month
 Subacute: Duration of 1-3 months
 Persistent: Duration of more than 3 months
 Specify current severity:
 Mild: Difficulty maintaining daytime
alertness 1-2 days/week
 Moderate: Difficulty maintaining daytime
alertness 3-4 days/week
 Severe: Difficulty maintaining daytime
alertness 5-7 days/week
Narcolepsy – Episodes of irresistible attacks of refreshing
sleep occurring daily, accompanied by episodes of brief loss
of muscle tone (cataplexy). People with narcolepsy
periodically progress right to this dream-sleep stage almost
directly from the state of being awake.
Two characteristics distinguish people who have
narcolepsy:
 Sleep paralysis – brief period after awakening
when they can’t move or speak that is often
frightening to those who go through it.
 Hypnagogic hallucinations – vivid and often
terrifying experiences that begin at the start of sleep
and are said to be unbelievably realistic because
they include not only visual aspects but also touch,
hearing, and even the sensation of body movement.
(e.g. being caught in a fire)
Diagnostic Criteria for Narcolepsy
 Recurrent periods of an irrepressible need to sleep,
lapsing into sleep, or napping occurring within the
same day. These must have been occurring at least
three times per week over the past 3 months.
 Episodes of cataplexy
 In individuals with long-standing disease,
brief (seconds to minutes) episodes of
sudden bilateral loss of muscle tone with
maintained consciousness that are
precipitated by laughter or joking.
 In children or in individuals within 6 months
of onset, spontaneous grimaces or jaw-
opening episodes with tongue thrusting or a
global hypotonia, without any obvious
emotional triggers.
 Hypocretin deficiency
 Nocturnal sleep polysomnography showing rapid
eye movement (REM) sleep latency less than or
equal to 15 minutes, or a multiple sleep latency test
showing a mean sleep latency less than or equal to
8 minutes and two or more sleep-onset REM
periods.
 Specify current severity:
 Mild: Infrequent cataplexy (less than once
per week), need for naps only once or twice
per day, and less disturbed nocturnal sleep.
 Moderate: Cataplexy once daily or every
few days, disturbed nocturnal sleep, and
need for multiple naps daily.
 Severe: Drug-resistant cataplexy with
multiple attacks daily, nearly constant
sleepiness, and disturbed nocturnal sleep
(i.e., movements, insomnia, and vivid
dreaming).
BREATHE-RELATED SLEEP DISORDERS – A variety of
breathing disorders that occur during sleep and that lead to
excessive sleepiness or insomnia. Sleepiness during the day
or disrupted sleep at night has a physical origin. Problems
with breathing while asleep.
 Sleep apnea – breathing is constricted that there
may be short periods (10 to 30 seconds) when they
stop breathing altogether.
 Sleep attacks – heavy sweating during the night,
morning headaches, and episodes of falling asleep
during the day with no resulting feeling of being
rested.
Three Types of Apnea
Obstructive sleep apnea hypopnea syndrome [327.23
(G47.33)] – occurs when airflow stops despite continued
activity by the respiratory system. Polysomnography:
 Nocturnal breathing disturbances: snoring,
snorting/gasping, or breathing pauses during sleep.
 Daytime sleepiness, fatigue, or unrefreshing sleep
despite sufficient opportunities to sleep that is not
better explained by another mental disorder
(including a sleep disorder) and is not attributable to
another medical condition
 15 or more obstructive apneas and/or hypopneas
per hour of sleep regardless of accompanying
symptoms.
 Specify current severity:
Mild: Apnea hypopnea index is less than 15.
Moderate: Apnea hypopnea Index is 15-30.
Severe: Apnea hypopnea index is greater than 30.
Central sleep apnea – involves the complete cessation of
respiratory activity for brief periods and is often associated
with certain central nervous system disorders, such as
cerebral vascular disease, head trauma, and degenerative
disorders.
 Evidence by polysomnography of five or more
central apneas per hour of sleep.
Sleep-related hypoventilation – decrease in airflow without
a complete pause in breathing. This tends to cause an
increase in carbon dioxide (CO2) levels, because insufficient
air is exchanged with the environment.
Circadian Rhythm Sleep Disorder – A discrepancy
between the sleep–wake schedule required by a person to
be rested and the requirements of the person’s environment
(e.g., work schedules) that leads to excessive sleepiness or
insomnia.
 Characterized by disturbed sleep brought on by the
brain’s inability to synchronize its sleep patterns with
the current patterns of day and night.
 Jet lag type – rapidly crossing multiple time zones
 Shift work type – people work at night or must work
irregular hours; as a result, they may have problems
sleeping or experience excessive sleepiness during
waking hours.
 Delayed sleep phase type – Extreme night owls,
people who stay up late and sleep late.
 Advanced sleep phase type – “early to bed and
early to rise.”
 irregular sleep–wake type – people who
experience highly varied sleep cycles.
 non-24-hour sleep–wake type – sleeping on a 25-
or 26-hour cycle with later and later bedtimes
ultimately going throughout the day
 Specify if:
Episodic: Symptoms last at least 1 month but less
than 3 months.
Persistent: Symptoms last 3 months or longer.
Recurrent: Two or more episodes occur within the
space of 1 year.
PARASOMNIAS – Abnormal behaviors that occur during
sleep.
Sleep Terrors – Recurrent episodes of abrupt terror arousals
from sleep, usually beginning with a panicky scream. There
is intense fear and signs of autonomic arousal, such as
mydriasis, tachycardia, rapid breathing, and sweating, during
each episode. There is relative unresponsiveness to efforts
of others to comfort the person during the episode.
Sleepwalking – somnambulism; occurs during NREM sleep.
Repeated episodes of rising from bed during sleep and
walking about. While sleepwalking, the person has a blank,
staring face; is relatively unresponsive to the efforts of others
to communicate with him or her; and can be awakened only
with great difficulty.
Non-Rapid Eye Movement Sleep Arousal Disorders –
Recurrent episodes of incomplete awakening from sleep
usually occurring during the first third of the major sleep
episode.
 Sleep terror and sleepwalking
 No or little (e.g., only a single-visual-scene) dream
imagery is recalled.
 Amnesia for the episodes is present.
Nightmares (or nightmare disorder) [307.47 (F51.5)] –
occur during REM or dream, sleep terrors, and incomplete
awakening. Repeated occurrences of extended, extremely
dysphoric, and well-remembered dreams that usually involve
efforts to avoid threats to survival, security or physical
integrity and that generally occur during the second half of
the major sleep episode.
 Specify current severity: Severity can be rated by the
frequency with which the nightmares occur:
Mild: Less than one episode per week on average
Moderate: One or more episodes per week but less
than nightly
Severe: Episodes nightly
Rapid Eye Movement Sleep Behavior Disorder [327.42
(G47.52)] – Repeated episodes of arousal during sleep
associated with vocalization and/or complex motor
behaviors. These behaviors arise during rapid eye movement
(REM) sleep and therefore usually occur greater than 90
minutes after sleep onset, are more frequent during the later
portions of the sleep period, and uncommonly occur during
daytime naps.
Upon awakening from these episodes, the individual is
completely awake, alert, and not confused or disoriented.
 REM sleep without atonia on polysomnographic
recording.
 A history suggestive of REM sleep behavior disorder
and an established synucleinopathy diagnosis (e.g.,
Parkinson’s disease, multiple system atrophy).
Restless Legs Syndrome [333.94 (G25.81)] – Irresistible Treatment for Hypersomnolence Disorder – Treatment is
urges to move the legs as a result of unpleasant sensations medical (stimulant drugs). Causes may involve genetic link
(sometimes labeled “creeping,” “tugging,” or “pulling” in the and/or excess serotonin
limbs) (otherwise referred to as Willis-Ekbom disease).
Treatment for Breathing-Related Sleep Disorders –
 The urge to move the legs begins or worsens during Treatment using continuous positive air pressure (CPAP)
periods of rest or inactivity. machines is the gold standard; weight loss is also often
 The urge to move the legs is partially or totally prescribed.
relieved by movement.
Treatment for Circadian Rhythm Sleep–Wake Disorders
 The urge to move the legs is worse in the evening or
– Treatment includes phase delays to adjust bedtime and
at night than during the day or occurs only in the bright light to readjust biological clock.
evening or at night.
 The symptoms in Criteria occur at least three times
per week and have persisted for at least 3 months
Substance-Induced Sleep Disorder – Severe sleep
disturbance that is the result of substance intoxication or
withdrawal.
Treatment for Bulimia Nervosa – Drug treatment, such as
antidepressants. Short-term cognitive-behavioral therapy
(CBT) to address behavior and attitudes on eating and body
shape. Interpersonal psychotherapy (IPT) to improve
interpersonal functioning. Tends to be chronic if left untreated
Treatment for Anorexia Nervosa – Hospitalization (at 70%
below normal weight). Outpatient treatment to restore weight
and correct dysfunctional attitudes on eating and body shape.
Family therapy. Tends to be chronic if left untreated; more
resistant to treatment than bulimia.
Treatment for Binge-Eating Disorder – Short-term CBT to
address behavior and attitudes on eating and body shape.
IPT to improve interpersonal functioning. Drug treatments
that reduce feelings of hunger. Self-help approached.
Causes of Eating Disorder:

Treatment for Insomnia Disorder – Treatment may be

medical (benzodiazepines) or psychological (anxiety
reduction, improved sleep hygiene); combined approach is
usually most effective.
Treatment for Narcolepsy – Treatment is medical (stimulant
drugs). Causes are likely to be genetic.
 PERSONALITY DISORDERS
Are personality disorders just an extreme variant of normal
personality, or are they distinctly different disorders?
Personality disorders are chronic; they do not come and go
but originate in childhood and continue throughout adulthood.
Many people who have personality disorders in addition to
other psychological problems (e.g. major depression) tend to
do poorly in treatment. Personality disorders is controversial,
because it involves a number of unresolved issues.
Personality disorder – is a persistent pattern of emotions,
cognitions, and behavior that results in enduring emotional
distress for the person affected and/or for others and may
cause difficulties with work and relationships.
 Countertransference – emotions of therapists
brought out by clients. Tend to be negative for those
diagnosed with personality disorders.
 Therapists especially need to guard against letting
their personal feelings interfere with treatment when
working with people who have personality disorders.
CATEGORICAL AND DIMENSIONAL MODEL
People with personality disorders display problem
characteristics over extended periods such that they are just
extreme versions of the problems many of us experience
temporarily, such as being shy or suspicious. (Degree of
difficulty)
Categories – ways of relating that are different from
psychologically healthy behavior. (Label people’s size
categorically, as tall, average, or short.)
Dimension – personality disorders are extreme versions of
otherwise normal personality variations. (height can be
viewed dimensionally, in inches or centimeters.)
The DSM doesn’t rate how dependent you are; if you meet
the criteria, you are labeled as having dependent personality
disorder. There is no “somewhat” when it comes to
personality disorders.
Five factors or dimensions of Personality
 Extroversion – talkative, assertive, and active
versus silent, passive, and reserved.
 Agreeableness – kind, trusting, and warm versus
hostile, selfish, and mistrustful.
 Conscientiousness – organized, thorough, and
reliable versus careless, negligent, and unreliable.
 Neuroticism – even-tempered versus nervous,
moody, and temperamental.
 Openness to experience – imaginative, curious,
and creative versus shallow and imperceptive.
PERSONALITY DISORDER CLUSTERS
Cluster A Personality Disorders (the odd or eccentric
cluster) – it includes paranoid, schizoid, and schizotypal
personality disorders.
Paranoid personality disorder [301.0 (F60.0)] –
excessively mistrustful and suspicious of others, without any
justification. They assume other people are out to harm or
trick them. These individuals are sensitive to criticism and
have an excessive need for autonomy.
A pervasive distrust and suspiciousness of others such that
their motives are interpreted as malevolent. Beginning by
early adulthood and present in a variety of contexts. Present
four or more of the following symptoms:
 Suspects, without sufficient basis, that others are
exploiting, harming, or deceiving him or her.
 Is preoccupied with unjustified doubts about the
loyalty or trustworthiness of friends or associates.
 Is reluctant to confide in others because of
unwarranted fear that the information will be used
maliciously against him or her.
 Reads hidden demeaning or threatening meanings
into benign remarks or events.
 Persistently bears grudges, i.e., is unforgiving of
insults, injuries, or slights.
 Perceives attacks on his or her character or
reputation that are not apparent to others and is
quick to react angrily or to counterattack.
 Has recurrent suspicions, without justification,
regarding fidelity of spouse or sexual partner.
 Note: If criteria are met prior to the onset of
schizophrenia, add “premorbid,” i.e., “paranoid
personality disorder (premorbid).”
Schizoid Personality Disorder [301.20 (F60.1)] – A
pervasive pattern of detachment from social relationships
and a restricted range of expression of emotions in
interpersonal settings, beginning by early adulthood and
present in a variety of contexts. They seem aloof, cold, and
indifferent to other people.
These people seem neither to desire nor to enjoy closeness
with others, including romantic or sexual relationships. As a
result, they appear cold and detached and do not seem
affected by praise or criticism. Present four or more of the
following symptoms:
  Neither desires nor enjoys close relationships,
including being part of a family.
 Almost always chooses solitary activities.
 Has little, if any, interest in having sexual
experiences with another person.
 Takes pleasure in few, if any, activities.
 Lacks close friends or confidants other than first-
degree relatives.
 Appears indifferent to the praise or criticism of
others.
 Shows emotional coldness, detachment, or flattened
affectivity.
Cluster B Personality Disorders (the dramatic, emotional,
 Note: If criteria are met prior to the onset of
or erratic cluster) – it consists of antisocial, borderline,
schizophrenia, add “premorbid,” i.e., “schizoid histrionic, and narcissistic personality disorders.
personality disorder (premorbid).”
Antisocial Personality Disorder [301.7 (F60.2)] – A
Schizotypal Personality Disorder [301.22 (F21)] – pervasive pattern of disregard for and violation of the rights
pervasive pattern of social and interpersonal deficits marked of others, occurring since age 15 years, as indicated by three
by acute discomfort with, and reduced capacity for, close (or more) of the following:
relationships as well as by cognitive or perceptual distortions
and eccentricities of behavior, beginning by early adulthood  Failure to conform to social norms with respect to
and present in a variety of contexts, as indicated by five (or lawful behaviors, as indicated by repeatedly
more) of the following: performing acts that are grounds for arrest.
 Deceitfulness, as indicated by repeated lying, use of
 Ideas of reference (excluding delusions of
aliases, or conning others for personal profit or
reference).
pleasure.
 Odd beliefs or magical thinking that influences
 Impulsivity or failure to plan ahead.
behavior and is inconsistent with subcultural norms
 Irritability and aggressiveness, as indicated by
(e.g., superstitiousness, belief in clairvoyance,
repeated physical fights or assaults.
telepathy, or “sixth sense”: in children and
 Reckless disregard for safety of self or others.
adolescents, bizarre fantasies or preoccupations).
 Consistent irresponsibility, as indicated by repeated
 Unusual perceptual experiences, including bodily
failure to sustain consistent work behavior or honor
illusions.
financial obligations.
 Odd thinking and speech (e.g., vague,
 Lack of remorse, as indicated by being indifferent to
circumstantial, metaphorical, overelaborate, or
or rationalizing having hurt, mistreated, or stolen
stereotyped).
from another.
 Suspiciousness or paranoid ideation.
 Inappropriate or constricted affect. The individual is at least age 18 years. There is evidence of
 Behavior or appearance that is odd, eccentric, or conduct disorder with onset before age 15 years. The
peculiar. occurrence of antisocial behavior is not exclusively during the
 Lack of close friends or confidants other than first- course of schizophrenia or bipolar disorder.
degree relatives.
 Tend to have long histories of violating the rights of
 Excessive social anxiety that does not diminish with
others.
familiarity and tends to be associated with paranoid
 They take what they want, indifferent to the concerns
fears rather than negative judgments about self.
of other people.
 Note: If criteria are met prior to the onset of
 Lying and cheating seem to be second nature to
schizophrenia, add “premorbid,” e.g., “schizotypal
them, and often they appear unable to tell the
personality disorder (premorbid).”
difference between the truth and the lies they make
up to further their own goals.
  Substance abuse is common
 Endophenotype—underlying aspects of a disorder
(such, antisocial) that might be more directly
influenced by genes.
Borderline Personality Disorder [301.83 (F60.3)] – A
pervasive pattern of instability of interpersonal relationships,
self-image, and affects, and marked impulsivity, beginning by
early adulthood and present in a variety of contexts, as
indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined
abandonment. (Note: Do not include suicidal or self-
mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal
relationships characterized by alternating between
extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently
unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially
self-damaging (e.g., spending, sex, substance
abuse, reckless driving, binge eating). (Note: Do not
include suicidal or self- mutilating behavior covered
in Criterion 5)
5. Recurrent suicidal behavior, gestures, or threats, or
self-mutilating behavior.
6. Affective instability due to a marked reactivity of
mood (e.g., intense episodic dysphoria, irritability, or
anxiety usually lasting a few hours and only rarely
more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling
anger (e.g., frequent displays of temper, constant
anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe
dissociative symptoms.
Borderline personality disorder is one of the most common
personality disorders observed in clinical settings; it is
observed in every culture. Dysfunction in the area of
emotion is sometimes considered one of the core features of
borderline personality disorder and is one of the best
predictors of suicide in this group.
Histrionic Personality Disorder [301.50 (F60.4)] – A
pervasive pattern of excessive emotionality and attention
seeking, beginning by early adulthood and present in a
variety of contexts, as indicated by five (or more) of the
following:
 Is uncomfortable in situations in which he or she is
not the center of attention.
 Interaction with others is often characterized by
inappropriate sexually seductive or provocative
behavior.
 Displays rapidly shifting and shallow expression of
emotions.
 Consistently uses physical appearance to draw
attention to self.
 Has a style of speech that is excessively
impressionistic and lacking in detail.
 Shows self-dramatization, theatricality, and
exaggerated expression of emotion.
 Is suggestible (i.e., easily influenced by others or
circumstances).
 Considers relationships to be more intimate than
they actually are.
They express their emotions in an exaggerated fashion, for
example, hugging someone they have just met or crying
uncontrollably during a sad movie.
Narcissistic Personality Disorder [301.81 (F60.81)] – A
pervasive pattern of grandiosity (in fantasy or behavior), need
for admiration, and lack of empathy, beginning by early
adulthood and present in a variety of contexts, as indicated
by five (or more) of the following:
 Has a grandiose sense of self-importance (e.g.,
exaggerates achievements and talents, expects to
be recognized as superior without commensurate
achievements).
 Is preoccupied with fantasies of unlimited success,
power, brilliance, beauty, or ideal love.
 Believes that he or she is “special” and unique and
can only be understood by, or should associate with,
other special or high-status people (or institutions).
 Requires excessive admiration.
 Has a sense of entitlement (i.e., unreasonable
expectations of especially favorable treatment or
automatic compliance with his or her expectations).
 Is interpersonally exploitative (i.e., takes advantage
of others to achieve his or her own ends).
 Lacks empathy. Is unwilling to recognize or identify
with the feelings and needs of others.
 Is often envious of others or believes that others are
envious of him or her.
 Shows arrogant, haughty behaviors or attitudes.
Cluster C Personality Disorders (anxious or fearful cluster)
– it includes avoidant, dependent, and obsessive-compulsive
personality disorders.
Avoidant Personality Disorder [301.82 (F60.6)] – A
pervasive pattern of social inhibition, feelings of inadequacy,
and hypersensitivity to negative evaluation, beginning by
early adulthood and present in a variety of contexts, as
indicated by four (or more) of the following:
 Avoids occupational activities that involve significant
interpersonal contact because of fears of criticism,
disapproval, or rejection.
 Is unwilling to get involved with people unless certain
of being liked.
 Shows restraint within intimate relationships
because of the fear of being shamed or ridiculed.
 Is preoccupied with being criticized or rejected in
social situations.
 Is inhibited in new interpersonal situations because
of feelings of inadequacy.
 Views self as socially inept, personally unappealing,
or inferior to others.
 Is unusually reluctant to take personal risks or to
engage in any new activities because they may
prove embarrassing.
They are extremely sensitive to the opinions of others and
although they desire social relationships.
Dependent Personality Disorder [301.6(F60.7)] – A
pervasive and excessive need to be taken care of that leads
to submissive and clinging behavior and fears of separation,
beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
 Has difficulty making everyday decisions without an
excessive amount of advice and reassurance from
others.
 Needs others to assume responsibility for most
major areas of his or her life.
 Has difficulty expressing disagreement with others
because of fear of loss of support or approval. (Note:
Do not include realistic fears of retribution.)
 Has difficulty initiating projects or doing things on his
or her own (because of a lack of self-confidence in
judgment or abilities rather than a lack of motivation
or energy).
 Goes to excessive lengths to obtain nurturance and
support from others, to the point of volunteering to
do things that are unpleasant.
 Feels uncomfortable or helpless when alone
because of exaggerated fears of being unable to
care for himself or herself.
 Urgently seeks another relationship as a source of
care and support when a close relationship ends.
 Is unrealistically preoccupied with fears of being left
to take care of himself or herself.
People with this disorder rely on others to make ordinary
decisions as well as important ones which results in an
unreasonable fear of abandonment.
Obsessive-Compulsive Personality Disorder [301.4
(F60.5)] – pervasive pattern of preoccupation with
orderliness, perfectionism, and mental and interpersonal
control, at the expense of flexibility, openness, and efficiency,
beginning by early adulthood and present in a variety of
contexts, as indicated by four (or more) of the following:
 Is preoccupied with details, rules, lists, order,
organization, or schedules to the extent that the
major point of the activity is lost.
 Shows perfectionism that interferes with task
completion (e.g., is unable to complete a project
because his or her own overly strict standards are
not met).
 Is excessively devoted to work and productivity to
the exclusion of leisure activities and friendships (not
accounted for by obvious economic necessity).
 Is over-conscientious, scrupulous, and inflexible
about matters of morality, ethics, or values (not
accounted for by cultural or religious identification).
 Is unable to discard worn-out or worthless objects
even when they have no sentimental value.
 Is reluctant to delegate tasks or to work with others
unless they submit to exactly his or her way of doing
things.
 Adopts a miserly spending style toward both self and
others; money is viewed as something to be hoarded
for future catastrophes.
 Shows rigidity and stubbornness.
OTHER RELATED PERSONALITY DISORDER
Conduct Disorder – diagnosis for children who engage in
behaviors that violate society’s norms.
 Childhood-onset type – the onset of at least one
criterion characteristic of CD prior to age 10 years.
 Adolescent-onset type – the absence of any
criteria characteristic of CD prior to age 10 years.
 “with a callous-unemotional presentation” –
young person presents in a way that suggests
personality characteristics similar to an adult with
psychopathy.
Diagnostic Criteria for Conduct Disorder  There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is the direct pathophysiological
consequence of another medical condition.

General Personality Disorder – An enduring pattern of

inner experience and behavior that deviates markedly from
the expectations of the individual’s culture. This pattern is
manifested in two (or more) of the following areas:

 Cognition (i.e., ways of perceiving and interpreting

self, other people, and events).
 Affectivity (i.e., the range, intensity, lability, and
appropriateness of emotional response).
 Interpersonal functioning.
 Impulse control.
The enduring pattern is inflexible and pervasive across a
broad range of personal and social situations. The enduring
pattern leads to clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and Its onset can
be traced back at least to adolescence or early adulthood.
Personality Change Due to Another Medical Condition
[310.1 (F07.0)] – A persistent personality disturbance that
represents a change from the individual’s previous
characteristic personality pattern.
 Note: In children, the disturbance involves a
marked deviation from normal development or a
significant change in the child’s usual behavior
patterns, lasting at least 1 year.
 SEXUAL DYSFUNCTIONS, PARAPHILIC DISORDERS, Criteria that have across Sexual Disorders:
AND GENDER DYSPHORIA
 The symptoms in Criteria have persisted for a
What is Normal Sexuality? minimum duration of approximately 6 months.
 he symptoms in Criteria cause clinically significant
SEXUAL BEHAVIORS AND DISORDER
distress in the individual.
Sexual dysfunction – find it difficult to function adequately  The sexual dysfunction is not better explained by a
while having sex; for example, they may not become aroused nonsexual mental disorder or as a consequence of
or achieve orgasm. severe relationship distress or other significant
stressors and is not attributable to the effects of a
Paraphilic disorder – the relatively new term for sexual
substance/medication or another medical condition.
deviation, sexual arousal occurs primarily in the context of
 Specify current severity: mild, moderate or extreme
inappropriate objects or individuals. Para means “abnormal”
distress over the symptoms in the criteria
and Philia means “strong attraction or liking”
Male Hypoactive Sexual Desire Disorder [302.71 (F52.0)]
Gender dysphoria – there is incongruence and
– have little or no interest in any type of sexual activity.
psychological distress and dissatisfaction with the gender
Persistently or recurrently deficient (or absent) sexual/erotic
one has been assigned at birth (boy or girl). Disturbance in
thoughts or fantasies and desire for sexual activity. The
the person’s sense of being a male or a female.
judgment of deficiency is made by the clinician, taking into
SEXUAL DYSFUNCTION – problems that arise in the account factors that affect sexual functioning, such as age
context of sexual interactions may occur in both heterosexual and general and sociocultural contexts of the individual’s life.
and homosexual relationships.
Female Sexual Interest/Arousal Disorder [302.72
Categories of Sexual Dysfunction Among Men and (F52.22)] – have little or no interest in any type of sexual
Women activity. Lack of, or significantly reduced, sexual
Type of Men Women interest/arousal, as manifested by at least three of the
Disorder following:
Desire Male hypoactive Female sexual
sexual desire interest/arousal  Absent/reduced interest in sexual activity.
disorder disorder  Absent/reduced sexual/erotic thoughts or fantasies.
Arousal Erectile disorder Female sexual  No/reduced initiation of sexual activity, and typically
interest/arousal unreceptive to a partner’s attempts to initiate.
disorder  Absent/reduced sexual excitement/pleasure during
Orgasm Delayed Female orgasmic sexual activity in almost all or all (approximately
ejaculation; disorder 75%-100%) sexual encounters (in identified
premature (early)
situational contexts or, if generalized, in all
ejaculation
contexts).
Pain Genito-pelvic
pain/penetration  Absent/reduced sexual interest/arousal in response
disorder to any internal or external sexual/erotic cues (e.g.,
written, verbal, visual).
 Absent/reduced genital or non-genital sensations
Sexual dysfunctions can be: (this also found in the criteria) during sexual activity in almost all or all
 Lifelong – chronic condition that is present during a (approximately 75%-100%) sexual encounters (in
person’s entire sexual life. identified situational contexts or, if generalized, in all
 Acquired – begins after sexual activity has been contexts).
relatively normal. SEXUAL AROUSAL DISORDERS
 Generalized – occurring every time the individual
attempts sex Erectile Disorder [302.72 (F52.21)] – At least one of the
 Situational – occurring with some partners or at three following symptoms must be experienced on almost all
certain times but not with other partners or at other or all (approximately 75%-100%) occasions of sexual activity
time
(in identified situational contexts or, if generalized, in all
contexts):
 Marked difficulty in obtaining an erection during
sexual activity.
 Marked difficulty in maintaining an erection until the
completion of sexual activity.
 Marked decrease in erectile rigidity.
Impotence and frigidity – derogatory term for male erectile
disorder and female interest and arousal difficulties. Many
males with erectile dysfunction have frequent sexual urges
and fantasies and a strong desire to have sex. Their problem
is in becoming physically aroused: For females who are also
likely to have low interest, deficits in arousal are reflected in
an inability to achieve or maintain adequate lubrication.
ORGASM DISODERS – orgasm occurs at an inappropriate
time or it does not occur.
Delayed ejaculation [302.74 (F52.32)] – Males who
achieve orgasm only with great difficulty or not at all meet
criteria for a condition. It can also mark infrequency or
absence of ejaculation.
Premature ejaculation [302.75 (F52.4)] – occurs well
before the man and his partner wish it to. A persistent or
recurrent pattern of ejaculation occurring during partnered
sexual activity within approximately 1 minute following
vaginal penetration and before the person wishes it. Note:
Although the diagnosis of premature (early) ejaculation may
be applied to individuals engaged in nonvaginal sexual
activities, specific duration criteria have not been established
for these activities.
Retrograde ejaculation – in which ejaculatory fluids travel
backward into the bladder rather than forward
Female orgasmic disorder [302.73 (F52.31)]– Females
who achieve orgasm only with great difficulty or not at all
meet criteria for a condition.
 Marked delay in, marked infrequency of, or absence
of orgasm.
 Markedly reduced intensity of orgasmic sensations.
SEXUAL PAIN DISORDER
Genito-pelvic pain/penetration disorder [302.76 (F52.6)] –
sexual dysfunction specific to women refers to difficulties with
penetration during attempted intercourse or significant pain
during intercourse.
 Vaginismus – in which the pelvic muscles in the
outer third of the vagina undergo involuntary spasms
when intercourse is attempted.
Persistent or recurrent difficulties with one (or more) of the
following:
 Vaginal penetration during intercourse.
 Marked vulvovaginal or pelvic pain during vaginal
intercourse or penetration attempts.
 Marked fear or anxiety about vulvovaginal or pelvic
pain in anticipation of, during, or as a result of
vaginal penetration.
 Marked tensing or tightening of the pelvic floor
muscles during attempted vaginal penetration.
Substance/Medication-Induced Sexual Dysfunction – A
clinically significant disturbance in sexual function is
predominant in the clinical picture. There is evidence from the
history, physical examination, or laboratory findings of both:
 The symptoms in Criteria 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 Criteria.
PARAPHILIC DISORDERS
Criteria that have across Paraphilic Disorders
 Over a period of at least 6 months, recurrent and
intense sexual arousal. intense sexually arousing
fantasies, sexual urges, or behaviors involving
sexual activity with *the disorder
 The fantasies, sexual urges, or behaviors cause
clinically significant distress or impairment in social,
occupational, or other important areas of
functioning.
 Specify if: in a controlled environment: This
specifier is primarily applicable to individuals living in
institutional or other settings where opportunities to
engage in *the disorder are restricted.
 In full remission: There has been no distress or
impairment in social, occupational, or other areas of
functioning for at least 5 years while in an
uncontrolled environment.
Fetishistic Disorder [302.81 (F65.0)] – person is sexually
attracted to nonliving objects. The fetish objects are not
limited to articles of clothing used in cross-dressing (as in
transvestic disorder) or devices specifically designed for the
purpose of tactile genital stimulation (e.g., vibrator).
Fetishistic arousal is associated with three classes of objects
or activities: inanimate object, or a source of specific
tactile stimulation, such as rubber. Partialism – part of the
body, such as the foot, buttocks, or hair.
Voyeuristic Disorder [302.82 (F65.3)] – practice of
observing, to become aroused, an unsuspecting individual
undressing or naked. he individual has acted on these sexual
urges with a nonconsenting person. The individual
experiencing the arousal and/or acting on the urges is at least
18 years of age.
Exhibitionistic Disorder [302.4 (F65.2)] – is achieving
sexual arousal and gratification by exposing genitals to
unsuspecting strangers. The individual has acted on these
sexual urges with a nonconsenting person. Specify whether:
 Sexually aroused by exposing genitals to
prepubertal children
 Sexually aroused by exposing genitals to physically
mature individuals
 Sexually aroused by exposing genitals to
prepubertal children and to physically mature
individuals
Transvestic Disorder [302.3 (F65.1)] – the act of (or
fantasies of) dressing in clothes of the opposite sex, or cross-
dressing. Specify if:
 With fetishism: If sexually aroused by fabrics,
materials, or garments.
 With autogynephilia: If sexually aroused by
thoughts or images of self as female.
Sexual Sadism Disorder [302.84 (F65.52)] – associated
with either inflicting pain or humiliation and becoming
sexually aroused is specifically associated with violence and
injury in these conditions. The individual has acted on these
sexual urges with a nonconsenting person.
Hypoxiphilia – involves self-strangulation to reduce the flow
of oxygen to the brain and enhance the sensation of orgasm.
Sadistic Rape – After murder, rape is the most devastating
assault one person can make on another. many rapists meet
criteria for antisocial personality disorder.
Sexual Masochism Disorders [302.83 (F65.51)] – suffering
pain or humiliation and becoming sexually aroused is
specifically associated with violence and injury in these
conditions. Specify if:
 With asphyxiophilia: If the individual engages in
the practice of achieving sexual arousal related to
restriction of breathing.
Pedophilic Disorder – sexual attraction to children (or young
adolescents generally aged 13 years or younger). Catholic
church, where priests, many of whom undoubtedly met
criteria for pedophilic disorder
 The individual has acted on these sexual urges, or
the sexual urges or fantasies cause marked distress
or interpersonal difficulty.
 The individual is at least age 16 years and at least 5
years older than the child or children. Note: Do not
include an individual in late adolescence involved in
an ongoing sexual relationship with a 12- or 13-year-
old.
 Specify whether: Exclusive type (attracted only to
children) or Nonexclusive type.
Incest – children are the person’s relatives
Frotteuristic Disorder – recurrent and intense sexual
arousal from touching or rubbing against a nonconsenting
person, as manifested by fantasies, urges, or behaviors. The
individual has acted on these sexual urges with a
nonconsenting person.
Other Specified Paraphilic Disorder: zoophilia, telephone
scatologia (obscene phone calls), necrophilia (corpses),
zoophilia (animals), coprophilia (feces), klismaphilia
(enemas), or urophilia (urine).
GENDER DYSPHORIA – person’s physical sex (male or
female anatomy, also called “natal” sex) is not consistent with
the person’s sense of who he or she really is or with his or
her experienced gender. Often feel trapped in a body of the
wrong sex
Gender Dysphoria in Children [302.6 (F64.2)] – At least 6
months’ duration, as manifested by at least six of the
following (one of which must be Criterion A1):
1. A strong desire to be of 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: or in girls, a strong
preference for wearing only typical masculine
clothing and a strong resistance to the wearing of
typical feminine clothing.
3. A strong preference for cross-gender roles in make-
believe play or fantasy play.
 4. A strong preference for the toys, games, or activities  Relapse prevention: Therapeutic preparation for
stereotypically used or engaged in by the other coping with future situations
gender. Orgasmic reconditioning: Pairing appropriate stimuli
5. A strong preference for playmates of the other with masturbation to create positive arousal patterns
gender.  Medical: Drugs that reduce testosterone to
6. In boys, a strong rejection of typically masculine suppress sexual desire; fantasies and arousal return
toys, games, and activities and a strong avoidance when drugs are stopped.
of rough-and-tumble play; or in girls, a strong
rejection of typically feminine toys, games, and Treatment for Sexual Dysfunction – Psychosocial:
activities. Therapeutic program to facilitate communication, improve
7. A strong dislike of one’s sexual anatomy. sexual education, and eliminate anxiety. Both partners
8. A strong desire for the primary and/or secondary sex participate fully. Medical: Almost all interventions focus on
characteristics that match one’s experienced male erectile disorder, including drugs, prostheses, and
gender. surgery. Medical treatment is combined with sexual
education and therapy to achieve maximum benefit.
The condition is associated with clinically significant distress
or impairment in social, school, or other important areas of Causes of Gender Dysphoria
functioning. Specify if; With a disorder of sex development.
Gender Dysphoria in Adolescents and Adults 302.85
[(F64.1 )] – at least 6 months’ duration. Incongruence
between one’s experienced or expressed gender and primary
and/or secondary sex characteristics A strong desire to be rid Causes of Paraphilic Disorder – Preexisting deficiencies –
of one’s primary and/or secondary sex characteristics. For In levels of arousal with consensual adults – In consensual
Adolescents, a desire to prevent the development of the adult social skills. Treatment received from adults during
anticipated secondary sex characteristics. childhood. Early sexual fantasies reinforced by masturbation
and extremely strong sex drive combined with uncontrollable
 A strong desire for the primary and/or secondary sex
thought processes.
characteristics of the other gender. A strong desire
to be of the other gender.
 A strong desire to be treated as the other gender. A
strong conviction that one has the typical feelings
and reactions of the other gender.
 Specify if: Post transition: The individual has
transitioned to full-time living in the desired gender
and has undergone (or is preparing to have) at least
one cross-sex medical procedure or treatment Causes of Sexual Dysfunction
regimen; cross-sex hormone treatment or gender
reassignment surgery confirming the desired gender
Treatment for Gender Dysphoria – Sex reassignment
surgery: removal of breasts or penis; genital reconstruction –
Requires rigorous psychological preparation and financial
and social stability. Psychosocial intervention to change
gender identity – Usually unsuccessful except as temporary
relief until surgery
Treatment for Paraphilic Disorders

 Covert sensitization: Repeated mental reviewing

of aversive consequences to establish negative
associations with behavior
 SUBSTANCE-RELATED, ADDICTIVE, AND IMPULSE-
CONTROL DISORDERS
These disorders have cursed us for centuries and continue
to affect how we live, work, and play
Substance-related and addictive disorders – are
associated with the abuse of drugs and other substances
people take to alter the way they think, feel, and behave.
Polysubstance use – using multiple substances.
Impulse-control disorders – represent a number of related
problems that involve the inability to resist acting on a drive
or temptation. (impulse to steal or to set fire)
LEVELS OF INVOLVEMENT
Substance – refers to chemical compounds that are ingested
to alter mood or behavior.
Psychoactive substances – alter mood, behavior, or both.
Safe/Legal drugs – also affect mood and behavior, they can
be addictive. (e.g. alcohol, the nicotine found in tobacco, and
the caffeine in coffee, soft drinks, and chocolate.)
Substance Use – ingestion of psychoactive substances in
moderate amounts that does not significantly interfere with
social, educational, or occupational functioning.
Substance Intoxication – physiological reaction to ingested
substances—drunkenness or getting high.
Substance abuse – how much of a substance is ingested is
problematic. How significantly it interferes with the user’s life
such disrupt your education, job, or relationships with others,
and put you in physically dangerous situations.
Substance Dependence (Addiction) – the person is
physiologically dependent on the drug or drugs.
 Tolerance – requires increasingly greater amounts
of the drug to experience the same effect.
 Withdrawal – respond physically in a negative way
when the substance is no longer ingested.
Withdrawal from many substances can bring on headache,
chills, fever, diarrhea, nausea and vomiting, and aches and
pains. Even hallucinations and body tremors in alcohol.
 Cocaine withdrawal has a pattern that includes
anxiety, lack of motivation, and boredom
 Cannabis withdrawal includes such symptoms as
nervousness, appetite change, and sleep
disturbance
Drug-seeking Behaviors – The repeated use of a drug, a
desperate need to ingest more of the substance (stealing
money to buy drugs, standing outside in the cold to smoke),
and the likelihood that use will resume after a period of
abstinence are behaviors that define the extent of drug
dependence.
Substance-related disorders categorized as “sociopathic
personality disturbances” including 11 symptoms and are
now described by levels of severity;
 Mild – the person exhibits only two or three of the 11
criteria met. (substance use results in a failure to
fulfill major role obligations)
 Moderate – four or five criteria met
 Severe – six or more criteria met. (occupational or
recreational activities are given up or reduced
because of substance use)
PSYCHOACTIVE DRUGS
Depressants: These substances result in behavioral
sedation and can induce relaxation. They include alcohol
(ethyl alcohol) and the sedative and hypnotic drugs in the
families of barbiturates (for example, Seconal) and
benzodiazepines (for example, Valium, Xanax).
Stimulants: These substances cause us to be more active
and alert and can elevate mood. Included in this group are
amphetamines, cocaine, nicotine, and caffeine.
Opiates: The major effect of these substances is to produce
analgesia temporarily (reduce pain) and euphoria. Heroin,
opium, codeine, and morphine are included in this group.
Hallucinogens: These substances alter sensory perception
and can produce delusions, paranoia, and hallucinations.
Cannabis and LSD are included in this category.
Other Drugs of Abuse: Other substances that are abused
but do not fit neatly into one of the categories here include
inhalants (for example, airplane glue), anabolic steroids, and
other over-the-counter and prescription medications (for
example, nitrous oxide). These substances produce a variety
of psychoactive effects that are characteristic of the
substances described in the previous categories.
Gambling Disorder: As with the ingestion of the substances
just described, individuals who display gambling disorder are
unable to resist the urge to gamble which, in turn, results in
negative personal consequences (e.g., divorce, loss of
employment).
Criteria present across all substance-related disorder. The
underline indicates the disorder.
 A problematic pattern of ______ leading to clinically
significant impairment or distress, as manifested by
at least two of the following, occurring within a 12-
month period
 ______ is often taken in larger amounts or over a
longer period than was intended.
 There is a persistent desire or unsuccessful efforts
to cut down or control _____ use.
 A great deal of time is spent in activities necessary
to obtain alcohol, use ___, or recover from its effects.
 Craving, or a strong desire or urge to use ______.
 Recurrent alcohol use resulting in a failure to fulfill
major role obligations at work, school, or home. (e.g.
repeated absences from work or poor work
performance related. Absences, suspensions, or
expulsions from school; neglect of children or
household.)
 Continued _____ use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol.
 Important social, occupational, or recreational
activities are given up or reduced because of __ use.
 Recurrent _____ use in situations in which it is
physically hazardous.
 ______ use is continued despite knowledge of
having a persistent or recurrent physical or
psychological problem that is likely to have been
caused or exacerbated by ______.
 Tolerance and Withdrawal
Specify if:
 In early remission: After full criteria for alcohol use
disorder were previously met, none of the criteria for
alcohol use disorder have been met for at least 3
months but for less than 12 months (with the
exception that bullet no. 4).
 In sustained remission: After full criteria for alcohol
use disorder were previously met, none of the
criteria for alcohol use disorder have been met at
any time during a period of 12 months or longer (with
the exception that bullet no. 4).
Criteria present across all intoxication related in every
disorder:
 Recent ingestion of ___
 Clinically significant problematic behavioral or
psychological changes that developed during, or
shortly after, ______ ingestion.
 One (or more) of the following signs or symptoms
developing during, or shortly after, ______ use:
Criteria present across all withdrawal related in every
disorder.
 Cessation of (or reduction in) _____ use that has
been heavy and prolonged.
 Two (or more) of the following, developing within
several hours to a few days:
DEPRESSANTS – decrease central nervous system activity.
Included in this group are alcohol and the sedative, hypnotic,
and anxiolytic drugs, such as those prescribed for insomnia.
Alcohol-Related Disorders
Alcohol Use Disorder – (the criteria for this disorder is given
on the “Criteria present across all substance-related disorder.
The underline indicates the disorder.”
Alcohol Intoxication – Slurred speech, Incoordination,
Unsteady gait, Nystagmus, Impairment in attention or
memory, Stupor or coma. Inappropriate sexual or aggressive
behavior, mood lability, impaired judgment.
Alcohol Withdrawal – Autonomic hyperactivity (e.g.,
sweating or pulse rate greater than 100 bpm). Increased
hand tremor. Insomnia. Nausea or vomiting. Transient visual,
tactile, or auditory hallucinations or illusions. Psychomotor
agitation. Anxiety. Generalized tonic-clonic seizures.
 Specify if: With perceptual disturbances: This
specifier applies in the rare instance when
hallucinations (usually visual or tactile) occur with
intact reality testing, or auditory, visual, or tactile
illusions occur in the absence of a delirium.
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders –
sedative (calming), hypnotic (sleep-inducing), and anxiolytic
(anxiety-reducing) drugs.
 Barbiturates – (which include Amytal, Seconal, and
Nembutal) are a family of sedative drugs.
 Benzodiazepines – (which today include Valium,
Xanax, and Ativan) primarily to reduce anxiety.
Sedative, Hypnotic, or Anxiolytic Intoxication – same as
alcohol intoxication criteria
Sedative, Hypnotic, or Anxiolytic Withdrawal – same as
alcohol withdrawal criteria
STIMULANTS
Stimulant Use Disorder – the criteria for this disorder is
given on the “Criteria present across all substance-related
disorder. The underline indicates the disorder.”
Amphetamines – can induce feelings of elation and vigor
and can reduce fatigue. Amphetamines are prescribed for
people with narcolepsy. also reduce appetite; lose weight.
“boost” and stay awake. Significant behavioral symptoms,
such as euphoria or affective blunting (a lack of emotional
expression), changes in sociability, interpersonal sensitivity,
anxiety, tension, anger, stereotyped behaviors, impaired
judgment, and impaired social or occupational functioning.
Cocaine – derived from the leaves of the coca plant, a
flowering bush indigenous to South America. increases
alertness, produces euphoria, increases blood pressure and
pulse, and causes insomnia and loss of appetite.
 Cocaine-induced paranoia – experiencing
exaggerated fears that he would be caught or that
someone would steal his cocaine.
Stimulant Intoxication – Tachycardia or bradycardia.
Pupillary dilation. Elevated or lowered blood pressure.
Perspiration or chills. Nausea or vomiting. Evidence of weight
loss. Psychomotor agitation or retardation. Muscular
weakness, respiratory depression, chest pain, or cardiac
arrhythmias. Confusion, seizures, dyskinesias, dystonia, or
coma.
 Specify if: With perceptual disturbances
Stimulant Withdrawal – Fatigue. Vivid, unpleasant dreams.
Insomnia or hypersomnia. Increased appetite. Psychomotor
retardation or agitation.
Tobacco Use Disorder – cigarette smoking. The criteria for
this disorder is given on the “Criteria present across all
substance-related disorder. The underline indicates the
disorder.”
Nicotine – is inhaled into the lungs, where it enters the
bloodstream and reaches the brain and appears to stimulate
nicotinic acetylcholine receptors (nAChRs)—in the midbrain
reticular formation and the limbic system, the site of the
brain’s pleasure pathway.
 Severe depression is found to occur significantly
more often among people with nicotine dependence.
Tobacco Withdrawal – Irritability, frustration, or anger.
Anxiety. Difficulty concentrating. Increased appetite.
Restlessness. Depressed mood. Insomnia.
Caffeine-Related Disorder – Caffeine called the “gentle
stimulant” because it is thought to be the least harmful of all
addictive drugs. Found in tea, coffee, many cola drinks sold
today, and cocoa products.
Caffeine Intoxication – Recent consumption of caffeine
(typically a high dose well in excess of 250 mg). Five (or
more) of the following signs or symptoms developing during,
or shortly after, caffeine use: Restlessness. Nervousness.
Excitement. Insomnia. Flushed face. Diuresis.
Gastrointestinal disturbance. Muscle twitching. Rambling
flow of thought and speech. Tachycardia or cardiac
arrhythmia. Periods of inexhaustibility and Psychomotor
agitation.
Caffeine Withdrawal – Headache. Marked fatigue or
drowsiness. Dysphoric mood, depressed mood, or irritability.
Difficulty concentrating. Flu-like symptoms (nausea,
vomiting, or muscle pain/stiffness).
OPIOIDS – family of substances that includes natural
opiates, synthetic variations (heroin, methadone,
hydrocodone, oxycodone), and the comparable substances
that occur naturally in the brain (enkephalins, beta-
endorphins, and dynorphins).
 Opiate – refers to the natural chemicals in the opium
poppy that have a narcotic effect (they relieve pain
and induce sleep). Induce euphoria, drowsiness,
and slowed breathing.
Opioid Use Disorder – The criteria for this disorder is given
on the “Criteria present across all substance-related disorder.
The underline indicates the disorder.”
Opioid Intoxication – initial euphoria followed by apathy,
dysphoria, psychomotor agitation or retardation, impaired
judgment. Pupillary constriction (or pupillary dilation due to
anoxia from severe overdose). Drowsiness or coma. Slurred
speech. Impairment in attention or memory. Specify if: With
perceptual disturbances.
Opioid Withdrawal – Administration of an opioid antagonist
after a period of opioid use. Dysphoric mood. Nausea or
vomiting. Muscle aches. Lacrimation or rhinorrhea. Pupillary
dilation, piloerection, or sweating. Diarrhea. Yawning. Fever.
Insomnia.
Cannabis-Related Disorders – Cannabis (marijuana)
(Cannabis sativa) grows wild throughout the tropical and
temperate regions of the world, which accounts for one of its
nicknames, “weed.”. Include mood swings. Normal
experiences seem extremely funny, or the person might enter
a dreamlike state in which time seems to stand still.
Heightened sensory experiences, seeing vivid colors, or
appreciating the subtleties of music.
Cannabis Use Disorder – The criteria for this disorder is
given on the “Criteria present across all substance-related
disorder. The underline indicates the disorder.”
Cannabis Intoxication – Conjunctival injection. Increased
appetite. Dry mouth. Tachycardia. impaired motor
coordination, euphoria, anxiety, sensation of slowed time,
impaired judgment, social withdrawal. Specify if: With
perceptual disturbances.
Cannabis Withdrawal - Irritability, anger, or aggression.
Nervousness or anxiety. Sleep difficulty (e.g., insomnia,
disturbing dreams). Decreased appetite or weight loss.
Restlessness. Depressed mood. At least one of the following
physical symptoms causing significant discomfort: abdominal
pain, shakiness/tremors, sweating, fever, chills, or headache.
HALLUCINOGENS
LSD – (d-lysergic acid diethylamide), sometimes referred to
as “acid,” is the most common hallucinogenic drug. Feel dizzy
and had a noticeable desire to laugh.
Phencyclidine (or PCP) – is snorted, smoked, or injected
intravenously, and it causes impulsivity and aggressiveness.
Other Hallucinogens: psilocybin (found in certain species of
mushrooms), lysergic acid amide (found in the seeds of he
morning glory plant), dimethyltryptamine (DMT) (found in the
bark of the Virola tree, which grows in South and Central
America); and mescaline (found in the peyote cactus plant).
Hallucinogen Use Disorder –The criteria for this disorder is
given on the “Criteria present across all substance-related
disorder. The underline indicates the disorder.” (except
Phencyclidine)
Hallucinogen Intoxication – marked anxiety or depression,
ideas of reference, fear of “losing one’s mind,” paranoid
ideation, impaired judgment. Perceptual changes occurring
in a state of full wakefulness and alertness (e.g., subjective
intensification of perceptions, depersonalization,
derealization, illusions, hallucinations, synesthesia)
 Symptoms: Pupillary dilation. Tachycardia.
Sweating. Palpitations. Blurring of vision. Tremors.
Incoordination.
Hallucinogen Persisting Perception Disorder – Following
cessation of use of a hallucinogen, the reexperiencing of one
or more of the perceptual symptoms that were experienced
while intoxicated with the hallucinogen (e.g., geometric
hallucinations, false perceptions of movement in the
peripheral visual fields, flashes of color, intensified colors,
trails of images of moving objects, positive afterimages, halos
around objects, macropsia and micropsia).
Phencyclidine Use Disorder – The criteria for this disorder
is given on the “Criteria present across all substance-related
disorder. The underline indicates the disorder.” Note:
Withdrawal symptoms and signs are not established for
phencyclidines, and so this criterion does not apply.
(Withdrawal from phencyclidines has been reported in
animals but not documented in human users.)
Phencyclidine Intoxication – Vertical or horizontal
nystagmus. Hypertension or tachycardia. Numbness or
diminished responsiveness to pain. Ataxia. Dysarthria.
Muscle rigidity. Seizures or coma. Hyperacusis. belligerence,
assaultiveness, impulsiveness, unpredictability, psychomotor
agitation, impaired judgment.
INHALANTS – include a variety of substances found in
volatile solvents—making them available to breathe into the
lungs directly. Abusively include spray paint, hair spray, paint
thinner, gasoline, amyl nitrate, nitrous oxide (“laughing gas”),
nail polish remover, felt-tipped markers, airplane glue,
contact cement, dry-cleaning fluid, and spot remover.
 Have higher levels of anxiety and depression and
show more impulsive and fearless temperaments.
Includes dizziness, slurred speech, incoordination,
euphoria, and lethargy.
 Increase aggressive and antisocial behavior, and
long-term use can damage bone marrow, kidneys,
liver, and the brain
Sudden sniffing death – If inhalants users are startled, this
can cause a cardiac event that can lead to death.
Anabolic–androgenic steroids – focus on people with
asthma, anemia, breast cancer, and males with inadequate
sexual development.
Inhalant Use Disorder – The criteria for this disorder is given
on the “Criteria present across all substance-related disorder.
The underline indicates the disorder.”. Specify the particular
inhalant: When possible, the particular substance involved
should be named (e.g., “solvent use disorder'’).
Inhalant Intoxication – Recent intended or unintended
short-term, high-dose exposure to inhalant substances,
including volatile hydrocarbons such as toluene or gasoline.
 Dizziness. Nystagmus. Incoordination. Slurred
speech. Unsteady gait. Lethargy. Depressed
 reflexes. Psychomotor retardation. Tremor.
Generalized muscle weakness. Blurred vision or
diplopia. Stupor or coma. Euphoria.
GAMBLING DISORDER – same criteria in the first bullet and
the specify severity. The gambling behavior is not better
explained by a manic episode.
 Needs to gamble with increasing amounts of money
in order to achieve the desired excitement.
 Is restless or irritable when attempting to cut down
or stop gambling.
 Has made repeated unsuccessful efforts to control,
cut back, or stop gambling.
 Is often preoccupied with gambling (e.g., having
persistent thoughts of reliving past gambling
experiences, handicapping or planning the next
venture, or thinking of ways to get money with which
to gamble).
 Often gambles when feeling distressed (e.g.,
helpless, guilty, anxious, depressed).
 After losing money gambling, often returns another
day to get even (“chasing” one’s losses).
 Lies to conceal the extent of involvement with
gambling.
 Has jeopardized or lost a significant relationship,
job, or educational or career opportunity because of
gambling.
 Relies on others to provide money to relieve
desperate financial situations caused by gambling.
IMPULSE-CONTROL DISORDERS – Characterized by
inability to resist acting on a drive or temptation. Sufferers
often perceived by society as having a problem simply due to
a lack of “will”
Intermittent Explosive Disorder – they act on aggressive
impulses that result in serious assaults or destruction of
property. Recurrent behavioral outbursts representing a
failure to control aggressive impulses.
 Verbal aggression, occurring twice weekly, on
average, for a period of 3 months.
 Three behavioral outbursts involving damage or
destruction of property and/or physical assault
involving physical injury against animals or other
individuals occurring within a 12-month period.
 The magnitude of aggressiveness expressed during
the recurrent outbursts is grossly out of proportion to
the provocation or to any precipitating psychosocial
stressors.
 The recurrent aggressive outbursts are not
premeditated (i.e., they are impulsive and/ or anger-
based) and are not committed to achieve some
tangible objective (e.g., money, power, intimidation).
 Chronological age is at least 6 years (or equivalent
developmental level).
Additional to the Conduct Disorder: Specify if: With
limited prosocial emotions – persistently over at least 12
months and in multiple relationships and settings.
 Lack of remorse or guilt: Does not feel bad or guilty
when he or she does something wrong
 Callous—lack of empathy: Disregards and is
unconcerned about the feelings of others.
 Unconcerned about performance: Does not show
concern about poor/problematic performance at
school, at work, or in other important activities.
 Shallow or deficient affect: Does not express
feelings or show emotions to others, except in ways
that seem shallow, insincere, or superficial or when
emotional expressions are used for gain
Kleptomania – Recurrent failure to resist impulses to steal
objects that are not needed for personal use or for their
monetary value. Increasing sense of tension immediately
before committing the theft. Pleasure, gratification, or relief at
the time of committing the theft. The stealing is not committed
to express anger or vengeance and is not in response to a
delusion or a hallucination.
Pyromania – involves having an irresistible urge to set fires.
Deliberate and purposeful fire setting on more than one
occasion. Tension or affective arousal before the act.
Fascination with, interest in, curiosity about, or attraction to
fire and its situational contexts (e.g., paraphernalia, uses,
consequences). Pleasure, gratification, or relief when setting
fires or when witnessing or participating in their aftermath.
The fire setting is not done for monetary gain, as an
expression of sociopolitical ideology, to conceal criminal
activity, to express anger or vengeance, to improve one’s
living circumstances, in response to a delusion or
hallucination, or as a result of impaired judgment
Oppositional Defiant Disorder – A pattern of angry/irritable
mood, argumentative/defiant behavior, or vindictiveness
lasting at least 6 months as evidenced by at least four
symptoms from any of the following categories and exhibited
during interaction with at least one individual who is not a
sibling.
Angry/Irritable Mood: Often loses temper. Is often touchy or Treatment for Substance use disorders:
easily annoyed. Is often angry and resentful.
Argumentative/Defiant Behavior: Often argues with
authority figures or, for children and adolescents, with adults.
Often actively defies or refuses to comply with requests from
authority figures or with rules. Often deliberately annoys
others. Often blames others for his or her mistakes or
misbehavior.
Vindictiveness: Has been spiteful or vindictive at least twice
within the past 6 months.
For children younger than 5 years, the behavior should occur
on most days for a period of at least 6 months For individuals
5 years or older, the behavior should occur at least once per
week for at least 6 months unless they otherwise noted in
vindictiveness. Specify current severity:
 Mild: Symptoms are confined to only one setting
(e.g., at home, at school, at work, with peers).
 Moderate: Some symptoms are present in at least
two settings.
 Severe: Some symptoms are present in three or
more settings.
Treatment for Intermittent Explosive Disorder –
Cognitive-behavioral interventions (helping person identify
and avoid triggers for aggressive outbursts) and approaches
modeled after drug treatments appear most effective
Treatment for Kleptomania – Behavioral interventions or
antidepressant medication.
Treatment for Pyromania – Cognitive-behavioral
interventions (helping person identify signals triggering
urges, and teaching coping strategies to resist setting fires)
Causes of Substance Use Disorders:
  Does not occur exclusively during the course of
schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, or another
psychotic disorder and is not attributable to the
physiological effects of another medical condition.
 The sexual dysfunction is not better explained by a
nonsexual mental disorder or as a consequence of
severe relationship distress or other significant
stressors and is not attributable to these effects of a
substance/medication or another medical condition.
 The signs or symptoms are not attributable to
another medical condition and are not better
explained by another mental disorder, including
intoxication with another substance.

CRITERIA FOUND MOSTY IN ALL DISORDERS

 The ______ is not better explained by another

mental disorder, such as somatic symptom disorder,
generalized anxiety disorder, or obsessive-
compulsive disorder.
 The psychological and behavioral factors in the
criteria are not better explained by another mental
disorder (e.g., panic disorder, major depressive
disorder, posttraumatic stress disorder).
 The sign or symptoms cause clinically significant
distress or impairment in social, occupational, or
other important areas of functioning.
 The disturbance is not attributable to the
physiological effects of a substance (e.g., a drug of
abuse, medication) or another medical condition
(e.g., seizures).
 The disturbance is not better explained by another
mental disorder, such as schizophrenia or panic
disorder.
 The disturbance is not attributable to the
physiological effects of a substance (e.g., alcohol or
other drug of abuse, a medication) or a neurological
or other medical condition (e.g., partial complex
seizures, transient global amnesia, sequelae of a
closed head injury/traumatic brain injury, or other
neurological condition).
 The disturbance is not better explained by
dissociative identity disorder, posttraumatic stress
disorder, acute stress disorder, somatic symptom
disorder, or major or mild neurocognitive disorder.