Abnormal Psychology Reviewer
Abnormal Psychology Reviewer
Biological Influences – brain and the chemicals. NEUROSCIENCE AND ITS CONTRIBUTION TO
PSYCHOPATHOLOGY
Emotional Influences – can affect physiological responses
such as blood pressure, heart rate, and respiration. Emotions The Central Nervous System – processes all information
also changed the way people thought about situations received from our sense organs and reacts as necessary.
involving traumatic incidence and motivated them to behave Spinal Cord – facilitate the sending of messages to
in ways they didn’t want to. and from the brain. Most complex organ in the body.
Social Influences – Social and cultural factors make direct Neurons – control every thought and action. ( An
contributions to biology and behavior such as rejection, and average of 140 billion nerve is found in the brain.)
anxiety of the person to the society around him/her. Glia or Glial Cells – outnumber neurons by a ratio
of about 10 to 1. Passive cells that merely served to
Developmental Influences – One more influence affects us connect and insulate neurons. Serve to modulate
all—the passage of time. As time passes, many things about neurotransmitter activity.
ourselves and our environments change in important ways,
causing us to react differently at different ages. Thus, at Parts of a Neuron
certain times we may enter a developmental critical period Dendrites – have numerous receptors that receive
when we are more or less reactive to a given situation or messages in the form of chemical impulses from
influence than at other times. other nerve cells, which are converted into electrical
THE INTERACTION OF GENE AND THE ENVIRONMENT impulses.
Axon – transmits these impulses to other neurons.
Diatheses-Stress Model – individuals inherit tendencies to Synaptic cleft – space between the axon of one
express certain traits or behaviors, which may then be neuron and the dendrite of another. This space is of
activated under conditions of stress. A condition that makes great interest to psychopathologists.
someone susceptible to developing a disorder.
Neurotransmitters – biochemicals that are
released from the axon and transmit the impulse to
the dendrite receptors of another neuron.
The Structure of the Brain Parietal lobe – recognizing various sensations of
touch and monitoring body positioning
Hindbrain – Regulates many automatic activities. Lowest
Occipital lobe – integrating and making sense of
part of brain stem.
various visual inputs.
Cerebellum – controls motor coordination. Frontal lobe – most interesting from the point of
Suggests that abnormalities in the cerebellum may view of psychopathology. synthesizes all information
be associated with the psychological disorder received from other parts of the brain and decides
autism. how to respond. It is what enables us to relate to the
Pons – “bridge”, body movement, respiration, world around us and the people in it—to behave as
attention, sleep, arousal. social animals.
Medulla – Oblong area; heartbeat and respiration; Prefrontal Cortex – The front (or anterior)
sleeping, sneezing, coughing. of the frontal lobe, responsible for higher
cognitive functions such as thinking and
Midbrain – coordinates movement with sensory input. reasoning, planning for the future, as well
Reticular activating system – contributes to as long-term memory.
processes of arousal and tension, such as whether When studying areas of the brain for clues to
we are awake or asleep. psychopathology, most researchers focus on the frontal lobe
Forebrain of the cerebral cortex, as well as on the limbic system and the
basal ganglia.
Thalamus and hypothalamus – which are involved
broadly with regulating behavior and emotion. The Peripheral Nervous System – coordinates with the
Located at the top of the brain stem. brain stem to make sure the body is working properly.
At the Base of Forebrain: Somatic nervous system – controls the muscles. SAME.
Limbic System – Limbic means border, so named
because it is located around the edge of the center Autonomic nervous system – regulate the cardiovascular
of the brain. figures prominently in much of system (the heart and blood vessels) and the endocrine
psychopathology, includes such structures as the system, and to perform various other functions, including
hippocampus (sea horse), cingulate gyrus (girdle), aiding digestion and regulating body temperature.
septum (partition), and amygdala (almond). This Sympathetic nervous system – mobilizing the
system helps regulate our emotional experiences body during times of stress or danger by rapidly
and expressions and, to some extent, our ability to activating the organs and glands under its control.
learn and to control our impulses. It is also involved Parasympathetic nervous system – to balance the
with the basic drives of sex, aggression, hunger, and sympathetic system. Normalizing our arousal and
thirst. facilitating the storage of energy by helping the
Basal Ganglia – include the caudate (tailed) digestive process.
nucleus. control motor activity. Damage to this make
us change our posture or twitch or shake. Endocrine System – Each endocrine gland produces its
Cerebral Cortex – largest part, contains more than own chemical messenger, called a hormone, and releases it
80% of all neurons in CNS. provides us with our directly into the bloodstream. Endocrine regulation may play
distinctly human qualities, allowing us to look to the a role in depression, anxiety, schizophrenia, and other
future and plan, to reason, and to create. disorders
Left Hemisphere – responsible for verbal
Adrenal glands – produce epinephrine (also called
and other cognitive processes.
adrenaline) in response to stress.
Right Hemisphere – perceiving the world
Thyroid gland – produces thyroxine, which
around us and creating images.
facilitates energy metabolism and growth.
Each hemisphere consists of four separate areas or Lobes: Pituitary – master gland that produces a variety of
regulatory hormones.
Temporal lobe – recognizing various sights and
Gonadal glands – produce sex hormones such as
sounds and with long-term memory storage.
estrogen and testosterone.
Psychoneuroendocrinology – interdisciplinary area of behavior, mood and particularly the way we process
research that nervous system and endocrine system both information.
play roles in treating psychological disorder.
↓ Serotonin = instability, impulsivity, and the
hypothalamic–pituitary–adrenocortical – hypothalamus tendency to overreact to situations, aggression and,
connects to the adjacent pituitary gland, stimulate the cortical excessive sexual behavior and suicidal. Depression.
part of the adrenal glands, then surges of epinephrine tend to Major serotonin pathways in the brain: Cerebral
energize us, arouse us, and get our bodies ready for threat cortex, Thalamus, Basal ganglia, Dorsal raphe
or challenge. nucleus, Midbrain and Cerebellum.
Prozac – enhances serotonin’s effects by preventing
Neurotransmitters – brain circuits. More than 100 different
neurotransmitters, each with multiple receptors, are it from being absorbed; have been recalled by the
functioning in various parts of the nervous system. Two types FDA for dangerous cardiovascular side effects.
of neurotransmitters: Monoamines and Amino Acids. Norepinephrine – “noradrenaline”, controls basic bodily
Neurotransmitter function focuses primarily on what happens functions such as respiration. Influence the emergency
when activity levels change: reactions or alarm responses
Informal Observation – relies on the observer’s Personal Inventories – self-report questionnaires that
recollection, as well as interpretation, of the events. assess personal traits.
Formal observation – involves identifying specific Face validity – The wording of the questions seems
behaviors that are observable and measurable to fit the type of information desired.
(called an operational definition: the meaning of Minnesota Multiphasic Personality Inventory
the variable in a specific context or observation.) (MMPI) – most widely used in the United States.
Self-Monitoring – People can also observe their own Empirical approach, that is, the collection and
behavior to find patterns or self-observation. The goal here is evaluation of data. The administration of the MMPI
is straightforward. The individual being assessed
reads statements and answers either “true” or Images of Brain Functioning:
“false.”.
Positron emission tomography (PET) scan –
MMPI profile – summary of scores from an
injects a radioactive tracer into the bloodstream and
individual being clinically assessed.
assesses activity of parts of the brain according to
Intelligence Testing – measured the skills, children need to the amount of glucose they metabolize.
succeed in school, including tasks of attention, perception, Single photon emission computed tomography
memory, reasoning, and verbal comprehension. (SPECT) – works much like PET, although a
different tracer substance.
Stanford-Binet test
Functional MRI, or fMRI – enables researchers to
The test provided a score known as an intelligence
observe the brain “while it works” by taking repeated
quotient, or IQ. Initially, IQ scores were calculated by
scans.
using the child’s mental age.
Deviation IQ – A person’s score is compared only Psychophysiological Assessment – measurable changes
with scores of others of the same age. The IQ score, in the nervous system that reflect emotional or psychological
then, is an estimate of how much a child’s events.
performance in school will deviate from the average
Electroencephalogram (EEG) – Measuring electrical
performance of others of the same age
activity in the head related to the firing of a specific group of
Verbal scales – which measure vocabulary,
neurons reveals brain wave activity.
knowledge of facts, short-term memory, and verbal
reasoning skills A person’s brain waves can be assessed in both
Performance scales – which assess psychomotor waking and sleeping states.
abilities, nonverbal reasoning, and ability to learn Alpha Waves – a normal, healthy, relaxed adult,
new relationships. waking activities are characterized by a regular
pattern of changes in voltage.
Neuropsychological Testing – this method of testing
Event-related potential (ERP) or evoked potential
assesses brain dysfunction by observing the effects of the
– patterns are recorded in response to specific
dysfunction on the person’s ability to perform certain tasks.
events such as hearing a psychologically meaningful
Bender Visual–Motor Gestalt Test – often used in stimulus.
children where they copy the given cards to them.
Electrodermal responding – formerly referred to as
False Positive – times when the test shows a
galvanic skin response (GSR), which is a measure of sweat
problem when none exists
gland activity controlled by the peripheral nervous system.
False Negative – times when no problem is found
even though some difficulty is present Biofeedback – levels of physiological responding, such as
blood pressure readings, heartbeat, respiration.
NEUROIMAGING: PICTURES OF THE BRAIN
DIAGNOSING PSYCHOLOGICAL DISORDER
Neuroimaging – ability to look inside the nervous system
and take increasingly accurate pictures of the structure and Idiographic strategy – determine what is unique about an
function of the brain. individual’s personality, cultural background, or
circumstances.
Image of Brain Structure:
Nomothetic strategy – able to determine a general class of
X-rays problems to which the presenting problem belongs.
CAT scan or CT Scan – computerized axial Attempting to name or classify the problem.
tomography: locating abnormalities in the structure
or shape of the brain such as tumors. Classification construct groups or categories and to
Nuclear Magnetic resonance imaging (MRI) – assign objects or people to these categories on the
places a person in a magnetic field and uses radio basis of their shared attributes or relations.
waves to cause the brain to emit signals that reveal Taxonomy – classification of entities for scientific
shifts in the flow of blood, which, in return, indicate purposes such as insects, or animals.
brain activity.
Nosology – apply a taxonomic system to Axis I: Schizophrenia or mood disorder
psychological or medical phenomena or other Axis II: Chronic disorders of personality
clinical areas. Axis III: Physical disorders and conditions
Nomenclature – names or labels of the disorders Axis IV: Amount of psychosocial stress the person
that make up the nosology. reported
DSM-5 – to identify a specific psychological disorder Axis V: Current level of adaptive functioning
in the process of making a diagnosis.
DSM-IV and DSM-IV-TR
Classical or Pure Categorical Approach – assume that
every diagnosis has a clear underlying pathophysiological ICD-10
cause, such as a bacterial infection or a malfunctioning DSM-IV (1994) task force decided to rely as little as
endocrine system. (Essential) possible on a consensus of experts.
12 independent studies or field trials examined the
Dimensional Approach – we note the variety of cognitions, reliability and validity of alternative sets of definitions
moods, and behaviors with which the patient presents and or criteria and, in some cases, the possibility of
quantify them on a scale.(Nonessential) creating a new diagnosis.
if someone were to ask you to describe a dog, you could Most substantial change in DSM-IV was that the
easily give a general description (the essential, categorical distinction between organically based disorders and
characteristics), but you might not exactly describe a specific psychologically based disorders that was present in
dog. Dogs come in different colors, sizes, and even species previous editions was eliminated.
(the nonessential, dimensional variations) The Multiaxial Format in DSM-IV
Prototypical Approach – identifies certain essential Axis I: Pervasive developmental disorders, learning
characteristics of an entity so that you (and others) can disorders, motor skills disorders, and
classify it. (Essential and nonessential) communication disorders
Diagnosis before 1980 Axis II: Personality disorders & intellectual disability.
Axis III: Physical disorders and conditions
Emil Kraepelin – Early efforts to classify psychopathology
Axis IV: Reporting psychosocial and environmental
arose out of the biological tradition. Identified Dementia
problems
Praecox (Schizophrenia); deterioration of the brain that
Axis V: Current level of adaptive functioning
sometimes occurs with advancing age (dementia) and
develops earlier than it is supposed to, or “prematurely” DSM-5 (2013)
(praecox). He also identified manic depressive psychosis
what we known now as bipolar disorder. In collaboration with international leaders working
simultaneously on ICD-11 (2014)
WHO added a section classifying mental disorders to the New disorders are introduced and other disorders
sixth edition of the International Classification of Diseases have been reclassified
and Related Health Problems (ICD). Diagnostic and There have been some organizational and structural
Statistical Manual (DSM-I), published in 1952 by the changes in the diagnostic manual itself: the manual
American Psychiatric Association. Diagnostic and Statistical is divided into three main sections.
Manual (DSM-II). In 1969. 1st: introduces the manual and describes
DSM-III and DSM-III-R – Diagnostic and Statistical Manual how best to use it.
(DSM-III) (1980) – Under the leadership of Robert Spitzer. 2nd: presents the disorders themselves
3rd: descriptions of disorders or conditions
Take an atheoretical approach to diagnosis, relying that need further research before they can
on precise descriptions of the disorders rather qualify as official diagnoses.
psychoanalytic or biological theories Removal of the multiaxial system
The use of dimensional axes for rating severity,
Multiaxial System – allowed clinicians with possible
intensity frequency, or duration of specific disorders
psychological disorders to be rated on five dimensions, or
has also been substantially expanded.
axes.
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
Depressed mood most of the day, nearly every day Hypomanic Episode – a less severe version of a manic
Markedly diminished interest or pleasure in all, or episode that does not cause marked impairment in social or
almost all, activities most of the day, nearly every occupational functioning and need last only 4 days rather
day than a full week. Same criteria as the Manic Episode.
Significant weight loss when not dieting or weight THE STRUCTURE OF MOOD DISORDERS
gain. Note: in children, consider failure to make
expected weight gains. Individuals who experience either depression or mania are
Insomnia or hypersomnia nearly every day. said to suffer from a unipolar mood disorder, because their
Psychomotor agitation or retardation nearly every mood remains at one “pole” of the usual depression-mania
continuum.
day
Fatigue or loss of energy nearly every day Mixed Features – An individual can experience manic
Feelings of worthlessness or excessive or symptoms but feel somewhat depressed or anxious at the
inappropriate guilt (which may be delusional) nearly same time; or be depressed with a few symptoms of mania.
every day
Temporal course – patterns of recurrence and remittance.
Diminished ability to think or concentrate, or
Do they tend to recur? If they do:
indecisiveness, nearly every day (either by
subjective account or as observed by others) Full Remission – Does the patient recover fully for
Recurrent thoughts of death (not just fear of dying), at least two months between episodes?
recurrent suicidal ideation without a specific plan, Partial Remission – Do they partially recover
or a suicide attempt or a specific plan for retaining some depressive symptoms?
committing suicide
The importance of temporal course is that they contribute to
The duration of a major depressive episode, if untreated, is decisions on which diagnosis is appropriate. Predicting the
approximately 4 to 9 months. Most central indicators of a full future course of the disorder, as well as in choosing
major depressive episode are the physical changes appropriate treatments.
(sometimes called somatic or vegetative symptoms),
emotional shutdown and Anhedonia, loss of energy and Onset
inability to engage in pleasurable activities or have any “fun” Early onset: If onset is before age 21 years.
Mania (Manic Episode) – individuals find extreme pleasure Late onset: If onset is at age 21 years or older.
in every activity. Abnormally exaggerated elation, joy, or
Severity – based on the number of criterion symptoms, the
euphoria. “persistently increased goal-directed activity or
severity of those symptoms, and the degree of functional
energy”, hyperactive, flight of ideas.
disability.
Manic episode require a duration of only 1 week,
Mild: Few, if any, symptoms in excess of those
less if the episode is severe enough to require
required to make the diagnosis are present, the
hospitalization. Hospitalization could occur, for
intensity of the symptoms is distressing but
example, if the individual was engaging in a self-
destructive
manageable, and the symptoms result in minor thoughts and completed suicide more likely, and predicts a
impairment in social or occupational functioning. poorer outcome from treatment. (comorbid or not).
Moderate: The number of symptoms, intensity of
Mixed features – several (at least three) symptoms of mania
symptoms, and/or functional impairment are
or major depressive episodes both within major depressive
between those specified for “mild” and “severe.”
disorder and persistent depressive disorder.
Severe: The number of symptoms is substantially in
excess of that required to make the diagnosis, the Melancholic features – applies only if the full criteria for a
intensity of the symptoms is seriously distressing major depressive episode have been met. Severe somatic
and unmanageable, and the symptoms markedly (physical) symptoms, such as early-morning awakenings,
interfere with social and occupational functioning. weight loss, and anhedonia.
Configurations of Depression Catatonic features – absence of movement (a stuporous
state) or catalepsy. Also involve excessive but random or
“with pure dysthymic syndrome,” – one has not purposeless movement.
met criteria for a major depressive episode in at least
the preceding two years. Atypical features – most people with depression sleep less
“with persistent major depressive episode,” – and lose their appetite, individuals with this specifier
presence of a major depressive episode over at least consistently oversleep and overeat during their depression
a two-year period and therefore gain weight.
“with intermittent major depressive episodes,” –
Peripartum onset – period of time just before and just after
double depression the birth (postpartum).
“With intermittent major depressive episodes
with current episode” – Full criteria for a major Baby blues – minor adjustment in childbirth where
depressive episode are currently met, but there have new mothers may be tearful and have some
been periods of at least 8 weeks in at least the temporary mood swings, but these are normal
preceding 2 years with symptoms below the responses to the stresses of childbirth and
threshold for a full major depressive episode. disappear quickly. (not applicable in Peri Onset)
“With intermittent major depressive episodes, Peripartum Depression – difficulty understanding
without current episode” – Full criteria for a major why a mother is depressed, because they assume
depressive episode are not currently met, but there this is a joyous time.
has been one or more major depressive episodes in
Seasonal pattern – applies to recurrent major depressive
at least the preceding 2 years.
disorder (and also to bipolar disorders). Accompanies
Specifiers – describe depressive disorders. Symptoms may episodes that occur during certain seasons.
or may not accompany a depressive disorder; when they do,
Depressive Episode = ↑ late fall, ↓ Spring
they are often helpful in determining the most effective
treatment or likely course. Bipolar Disorder = Depressed: Winter, Manic:
Summer.
Psychotic features – hallucinations, delusions, somatic Seasonal affective disorder (SAD) – episodes
(physical) delusions, believing, for example, that their bodies must have occurred for at least two years with no
are rotting internally and auditory hallucinations. evidence of nonseasonal major depressive episodes
occurring during that period of time.
Mood Congruent – hallucination and delusion
directly related to the depression. Rapid-Cycling – applicable only in Bipolar Disorders. People
Mood-incongruent – types of hallucinations or move quickly in and out of depressive or manic episodes. An
delusions such as delusions of grandeur that do not individual with bipolar disorder who experiences at least four
seem consistent with the depressed mood. manic or depressive episodes within a year is considered to
Conditions in which psychotic symptoms have a rapid-cycling pattern.
accompany depressive episodes are relatively rare.
Rapid (mood) switching – direct transition from
Anxious distress – presence and severity of accompanying one mood state to another happens. It is a
anxiety. Indicates a more severe condition, makes suicidal treatment-resistant form of the disorder.
Specify the clinical status and/or features of the current or Double depression – individuals who suffer from both major
most recent major depressive episode: depressive episodes and persistent depression with fewer
Single episode or recurrent episode symptoms. Develop few depressive symptoms at early age
Mild, moderate, severe and will occur later and revert to major depressive episode.
With anxious distress Which will lead to severe psychopathology and a problematic
With mixed features future course.
With melancholic features
Onset and Duration
With atypical features
With mood-congruent psychotic features Developing major depression is fairly low until the
With mood-incongruent psychotic features early teens, when it begins to rise in a steady (linear)
With catatonia fashion.
With peripartum onset Mean age of onset for major depressive disorder is
With seasonal pattern (recurrent episode only) In partial 30 years.
remission, in full remission Children ages 5 to 12, 5% had experienced major
DEPRESSIVE DISORDERS – two factors that most depressive disorder. The corresponding figures in
importantly describe mood disorders are severity and adolescence (ages 13 to 17) was 19%; in emerging
chronicity. adulthood (ages 18 to 23), 24%; and in young
adulthood (ages 24 to 30) 16%.
Recurrence – If two or more major depressive Typical duration of the first episode being 2 to 9
episodes occurred and were separated by at least 2 months if untreated
months during which the individual was not
depressed. Premenstrual Dysphoric Disorder (PMDD) – combination
of physical symptoms, irritability, anger, severe mood swings
Major Depressive Disorder – At least one major depressive and anxiety are associated with incapacitation during this
episode. There has never been a manic episode or period of time. Criteria must have been met for most
hypomanic episode. menstrual cycles that occurred in the preceding year.
Persistent depressive disorder (dysthymia) – shares Decreased interest in usual activities (e.g., work,
many of the symptoms of major depressive disorder but school, friends, hobbies).
differs in course. But depression remains relatively Subjective difficulty in concentration.
unchanged over long periods, sometimes 20 or 30 years or Lethargy, easy fatigability, or marked lack of energy.
more Marked change in appetite; overeating; or specific
Continues at least 2 years, during which the patient food cravings.
cannot be symptom free for more than 2 months at Hypersomnia or insomnia.
a time. Note: In children and adolescents, mood can A sense of being overwhelmed or out of control.
be irritable and duration must be at least 1 year Physical symptoms such as breast tenderness or
During the 2-year period (1 year for children or swelling, joint or muscle pain, a sensation of
adolescents) of the disturbance, the person has “bloating”, or weight gain.
never been without the symptoms in criteria for
Disruptive Mood Dysregulation Disorder – Severe
more than 2 months at a time.
recurrent temper outburst manifested verbally (e.g., verbal
Presence, while depressed, of two (or more) of the rages) and/or behaviorally (e.g., physical aggression toward
following: Poor appetite or overeating, Insomnia or people or property) that are grossly out of proportion in
hypersomnia, Low energy or fatigue, Low self- intensity or duration to the situation or provocation.
esteem, Poor concentration or difficulty making
decisions, and Feelings of hopelessness. The temper outbursts are inconsistent with
Higher rates of comorbidity and slower rate of developmental level. The temper outbursts occur, on
improvement over time average, three or more times per week.
Less or fewer number of symptoms required/shown The mood between temper outbursts is persistently
Dysthymia – people suffering from mild persistent irritable or angry most of the day, nearly every day,
depression with fewer symptoms.
and is observable by others (e.g., parents, teachers, The average age of onset for bipolar I disorder is
peers). from 15 to 18 and for bipolar II disorder from 19 and
Criteria have been present for 12 or more months. 22, although cases of both can begin in childhood
Throughout that time, the individual has not had a Bipolar disorders begin more acutely; suddenly.
period lasting 3 or more consecutive months without Cyclothymia is chronic and lifelong
all of the symptoms.
Criteria are present in at least two of three settings A grief to Depression – Approximately 20% of bereaved
(i.e., at home, at school, with peers) and are severe individuals may experience a complicated grief reaction in
in at least one of these. which the normal grief response develops into a full-blown
mood disorder.
The diagnosis should not be made for the first time
before age 6 years or after age 18 years. Suicide
By history or observation, the age at onset of Criteria
is before 10 years. Suicide is often associated with mood disorders but
There has never been a distinct period lasting more can occur in their absence or in the presence of
than 1 day during which the full symptom criteria, other disorders. It is the 11th leading cause of death
except duration, for a manic or hypomanic episode among all people in the United States, but among
have been met. adolescents, it is the 3rd leading cause of death.
In understanding suicidal behavior, three indices are
BIPOLAR DISORDER – tendency of manic episodes to important: suicidal ideation (serious thoughts about
alternate with major depressive episodes in an unending committing suicide), suicidal plans (a detailed
roller-coaster ride from the peaks of elation to the depths of method for killing oneself), and suicidal attempts
despair. (that are not successful). Important, too, in learning
about risk factors for suicides is the psychological
Bipolar I – major depressive episodes alternate with full
autopsy, in which the psychological profile of an
manic episodes. There must be a symptom-free period of at
individual who has committed suicide is
least 2 months between them. Criteria have been met for at
reconstructed and examined for clues.
least one manic episode.
Causes of Mood Disorders
Bipolar II – at least one major depressive episode alternate
with at least one hypomanic episode. There has never been People with mood disorders experience one or both of the
a manic episode. following:
Cyclothymic disorder – chronic alternation of mood Mania: A frantic “high” with extreme overconfidence
elevation and depression that does not reach the severity of and energy, often leading to reckless behavior
manic or major depressive episodes. Depression: A devastating “low” with extreme lack
Tend to be in one mood state or the other for years of energy, interest, confidence, and enjoyment of
with relatively few periods of neutral (or euthymic) life.
mood. Biological Influences
This pattern must last for at least 2 years (1 year for
children and adolescents) to meet criteria for the Inherited vulnerability
disorder. Hypomanic and depressive periods have Altered neurotransmitters and neurohormonal
been present for at least half the time and the systems
individual has not been without the symptoms for Sleep deprivation
more than 2 months at a time. Circadian rhythm disturbances
Alternate between the kinds of mild depressive
Behavioral Influences
symptoms
Criteria for a major depressive, manic, or hypomanic Depression – General slowing down, neglect of
episode have never been met. responsibilities and appearance, irritability;
complaints about matters that used to be taken in
Onset and Duration
stride
Mania – Hyperactivity, Reckless or otherwise of a loved one) and develop skills to resolve interpersonal
unusual behavior. conflicts and build new relationships.
Emotional and Cognitive Influences Electroconvulsive Therapy – for severe depression, ECT is
used when other treatments have been ineffective. It usually
Depression – Emotional flatness or emptiness , has temporary side effects, such as memory loss and
inability to feel pleasure, poor memory, inability to lethargy. In some patients, certain intellectual and/or memory
concentrate, hopelessness and/or learned functions may be permanently lost.
helplessness, loss of sexual desire, loss of warm
feelings for family and friends, exaggerated self- Light Therapy – For seasonal affective disorder.
blame or guilt, overgeneralization, loss of self-
esteem, suicidal thoughts or actions
Mania – exaggerated feelings of euphoria and OTHER MOOD DISORDERS
excitement
Substance/Medication-Induced Depressive Disorder –
Social Influences depressive symptoms with evidence from the history,
physical examination, or laboratory findings of both:
Women and minorities—social inequality and
oppression and a diminished sense of control The symptoms in Criteria developed during or soon
Social support can reduce symptoms after substance intoxication or withdrawal or after
Lack of social support can aggravate symptoms exposure to a medication.
The involved substance/medication is capable of
Trigger producing the symptoms in Criteria.
Negative or positive life changes (death of a loved The symptoms persist for a substantial period of time (e.g.,
one, promotion, etc.) about 1 month) after the cessation of acute withdrawal or
Physical illness severe intoxication.
Treatment of Mood Disorders – is most effective and Depressive Disorder Due to Another Medical Condition –
easiest when it’s started early. Most people are treated with depressive symptoms with evidence from the history,
a combination of these methods. physical examination, or laboratory findings that the
Medications – antidepressants can help to control disturbance is the direct pathophysiological consequence of
symptoms and restore neurotransmitter functioning. another medical condition.
Tricyclics (Tofranil, Elavil) Other specified Depressive Disorder without meeting the
full criteria:
Monamine oxidase inhibitors (MAO inhibitors):
(Nardil, Parnate); MAO inhibitors can have severe Recurrent brief depression: Concurrent presence of
side effects, especially when combined with certain depressed mood and at least four other symptoms of
foods or over-the-counter medications depression for 2-13 days at least once per month.
Selective-serotonin reuptake inhibitors or SSRIs
(Prozac, Zoloft) are newer and cause fewer side Short-duration depressive episode (4-13 days):
effects than tricyclics or MAO inhibitors Depressed affect and at least four of the other eight
symptoms of a major depressive episode
Lithium is the preferred drug for bipolar disorder;
side effects can be serious; and dosage must be Depressive episode with insufficient symptoms:
carefully regulated Depressed affect and at least one of the other eight
symptoms of a major depressive episode for at least 2 weeks.
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
SOMATIC SYMPTOMS AND RELATED DISORDER AND Although any one symptom may not be
DISSOCIATIVE DISORDERS continuously present, the state of being
symptomatic is persistent (typically more than 6
Both are relatively rare and not well understood.
months).
Somatic symptom disorders – preoccupation with an Specify if: With predominant pain (previously pain
individual’s health or appearance becomes so great that it disorder): This specifier is for individuals whose
dominates their lives. Exaggerates the slightest physical somatic complaints predominantly involve pain.
symptom. Soma means body. Specify current severity:
Mild: Only one of the symptoms in Criteria
Grouped under “medically unexplained physical
is fulfilled.
symptoms”.
Moderate: Two or more of the symptoms
Dissociative disorders – dissociation or dissociative specified.
experiences; people experience alterations, or detachments, Severe: Two or more of the symptoms are
in consciousness or identity. (“This isn’t really me,” or “That fulfilled, plus there are multiple somatic
doesn’t really look like my hand,” or “There’s something complaints (or one very severe somatic
unreal about this place.”) symptom).
These experiences are so intense and extreme that 2. Illness Anxiety Disorder [300.7 (F45.21)] – formerly
they lose their identity entirely and assume a new known as “hypochondriasis,”. Preoccupation with fears of
one or they lose their memory or sense of reality and having or acquiring a serious illness. More worried on the
are unable to function. idea that an individual was either ill or developing an illness
than the specific physical symptoms.
“Hysterical neurosis.” – Somatic symptom and dissociative
disorders are strongly linked historically and share common Some examples: Public restrooms and, on occasion,
features. public telephones were feared as sources of
infection. Headache indicated a brain tumor and
FIVE BASIC SOMATIC SYMPTOMS breathlessness was an impending heart attack.
1. Somatic Symptom Disorder [300.82 (F45.1)] – known Somatic symptoms are not present or, if present, are
before as Briquet’s syndrome. People with somatic only mild in intensity.
symptom disorder do not always feel the urgency to take There is a high level of anxiety about health, and
action but continually feel weak and ill, and they avoid the individual is easily alarmed about personal
exercising, thinking it will make them worse. One or more health status.
physical symptoms are relatively severe and are associated The individual performs excessive health-related
with anxiety and distress behaviors. (e.g. regularly check for sign of illness)
Illness preoccupation has been present for at least 6
Physical symptoms – pain, breathlessness, months, but the specific illness that is feared may
headache and paralysis, etc. change over that period of time.
Diagnostic Criteria for Somatic Symptom Disorder Specify whether:
Care-seeking type: Medical care,
One or more somatic symptoms that are distressing including physician visits or undergoing
and/or result in significant disruption of daily life. tests and procedures, is frequently used.
Excessive thoughts, feelings, and behaviors related Care-avoidant type: Medical care is rarely
to the somatic symptoms or associated health used.
concerns as manifested by at least one of the
following: Somatic symptom disorder and illness anxiety disorder are
Disproportionate and persistent thoughts characterized by anxiety or fear that one has a serious
about the seriousness of one’s symptoms. disease but it differ from anxiety disorders because the
High level of health-related anxiety. individual is preoccupied with bodily symptoms.
Excessive time and energy devoted to
these symptoms or health concerns.
“disease conviction” – difficult-to-shake belief other important areas of functioning or warrants
where individuals mistakenly believe they have a medical evaluation.
disease.
Astasia-abasia – walking began to deteriorate, including
These disorders are spread fairly evenly across
weakness in legs and difficulty keeping balance, with the
various phases of adulthood.
result that an individual fell often. Until they cannot walk
Somatic symptom disorders are chronic, often anymore.
continuing into old age.
Psychogenic non-epileptic seizures – people have
Culture-specific syndromes seem to fit comfortably with seizures, which may be psychological in origin, because
somatic symptom disorders.
no significant electroencephalogram (EEG) changes can
Koro – Chinese belief that severe anxiety and be documented.
sometimes panic, that the genitals are retracting into Globus hystericus – sensation of a lump in the throat
the abdomen. (mostly males) that makes it difficult to swallow, eat, or sometimes talk.
Dhat – Indian belief that they are losing semen,
something that obviously occurs during sexual Distinguishing among conversion reactions, real physical
activity that results to dizziness, weakness, and disorders, and outright malingering (faking) is sometimes
fatigue. difficult.
Other culture-specific syndrome: Africa – hot
La belle indifference – patients with
sensations in the head or a sensation of something
conversion reactions had the same quality of
crawling in the head.
indifference to the symptoms thought to be
Pakistan and India – sensation of burning in the present in some people with severe somatic
hands and feet. symptom disorder. (later on, debunked)
3. Conversion Disorder (Functional Neurological People with conversion symptoms can usually
Symptom Disorder) – Freud popularized that anxiety function normally, they seem truly unaware
resulting from unconscious conflicts somehow was either of this ability or of sensory input. (e.g.
“converted” into physical symptoms to find expression. The blindness can usually avoid objects in their
ICD-9-CM code for conversion disorder is 300.11 visual field, but they will tell you they can’t see
the objects.)
“Functional” refers to a symptom without an
organic cause. Conversion disorder comorbid anxiety and mood disorders
Physical malfunctioning, such as paralysis, are also common and are relatively rare in mental health
blindness, or difficulty speaking (aphonia), without settings but remember that people who seek help for this
any physical or organic pathology to account for the condition are more likely to consult neurologists or other
malfunction. specialists.
Somebody going blind when all visual processes are Like severe somatic symptom disorder, conversion
normal or experiencing paralysis of the arms or legs disorders are found primarily in women. Typically
when there is no neurological damage. develop during adolescence or slightly thereafter.
Diagnostic Criteria for Conversion Disorder Conversion symptoms often disappear after a time,
only to return later in the same or similar form when
One or more symptoms of altered voluntary motor a new stressor occurs
or sensory function.
Clinical findings provide evidence of incompatibility 4. Factitious disorders – fall somewhere between
between the symptom and recognized neurological malingering and conversion disorders. Symptoms are under
or medical conditions. voluntary control, as with malingering, but there is no obvious
The symptom or deficit is not better explained by reason for voluntarily producing the symptoms except,
another medical or mental disorder. possibly, to assume the sick role and receive increased
attention.
The symptom or deficit causes clinically significant
distress or impairment in social, occupational, or Factitious disorder imposed on another –
formerly known as Munchausen syndrome by proxy.
Individual deliberately makes someone else sick. Brief somatic symptom disorder: Duration of
(e.g. mother injecting her own urine into the child’s symptoms is less than 6 months.
intravenous line so that she could take care of him.) Brief illness anxiety disorder: Duration of
True nature of the illness is most often unsuspected symptoms is less than 6 months.
and the people perceive the parents as remarkably Illness anxiety disorder without excessive
caring, cooperative, and involved in providing for health-related behaviors: Criteria for illness
their child’s well-being. anxiety disorder is not met.
Video surveillance was the method used to establish Pseudocyesis: A false belief of being pregnant that
the diagnosis and separating parent and child. is associated with objective signs and reported
symptoms of pregnancy.
Diagnostic Criteria for Factitious Disorder
DISSOCIATIVE DISORDERS – trigger from extremely
Falsification of physical or psychological signs or
stressful event, such as an accident; trauma and sleep
symptoms, or induction of injury or disease,
deprivation. One “dissociates” from reality.
associated with identified deception.
The individual presents himself or herself to others Depersonalization – perception alters so that you
as ill, impaired or injured. temporarily lose the sense of your own reality, as if you were
The deceptive behavior is evident even in the in a dream and you were watching yourself.
absence of obvious external rewards.
Things around them seemed unreal or dreamlike
The behavior is not better accounted for by another
and they felt time had stopped. They also felt
mental disorder such as delusional belief system or
estranged from other people and distant from their
acute psychosis
own emotions; a number of them felt they were
5. Psychological Factors Affecting Other Medical strangers to themselves.
Conditions – presence of a diagnosed medical condition
Derealization – your sense of the reality of the external world
such as asthma, diabetes, or severe pain clearly caused by
is lost. Things may seem to change shape or size; people
a known medical condition such as cancer that is adversely
may seem dead or mechanical.
affected (increased in frequency or severity) by one or more
psychological or behavioral factors. Disintegrated experiences – Cannot remember why we are
in a certain place or even who we are. Lose our sense that
A medical symptom or condition (other than a mental
our surroundings are real. Finally, begin thinking we are
disorder) is present.
somebody else—somebody who has a different personality,
Psychological or behavioral factors adversely affect
different memories, and even different physical reactions,
the medical condition in one of the following ways: such as allergies we never had.
The factors have influenced the course of
the medical condition as shown by a close Depersonalization-Derealization Disorder [300.6 (F48.1)]
temporal association between the – When feelings of unreality are so severe and frightening
psychological factors and the development that they dominate an individual’s life and prevent normal
or exacerbation of, or delayed recovery functioning.
from, the medical condition.
The presence of persistent or recurrent primary
The factors interfere with the treatment of
experiences of depersonalization, derealization, or
the medical condition (e.g., poor
both.
adherence).
The factors constitute additional well- During the depersonalization or derealization
established health risks for the individual. experience, reality testing remains intact.
The factors influence the underlying This disorder approximately equally split between
pathophysiology, precipitating or men and women.
exacerbating symptoms or necessitating Mean age of onset was 16 years, and the course
medical attention. tended to be chronic.
Anxiety, mood, and personality disorders are also
Other Specified Somatic Symptom and Related Disorder commonly found in these individuals.
(did not meet the full criteria).
“tunnel vision” (perceptual distortions) and “mind himself, he probably will not remember the episode.
emptiness” (difficulty absorbing new information) (mostly males)
Other symptoms: Looking at the world through a Running Amok – individual enters a trancelike state
fog, did not hear part of conversation, finding familiar and suddenly, imbued with a mysterious source of
place strange and unfamiliar, staring off into space; energy, runs or flees for a long time. (prevalent in
unaware of time, can’t remember if just did women)
something or thought it, do usually difficult things Pivloktoq – running amok term for Arctic Natives
with ease/ spontaneity, act so differently/feel like two Frenzy witchcraft – Navajo tribes’ term for running
different people and talk out loud to oneself when amok
alone.
Dissociative Identity Disorder [300.14 (F44.81)] – may
Dissociative Amnesia [300.12 (F44.0)] – severe adopt as many as 100 new identities, all simultaneously
dissociative disorders where there is an inability to recall coexisting, although the average number is closer to 15. In
important autobiographical information, usually of a traumatic some cases, the identities are complete, each with its own
or stressful nature, that is inconsistent with ordinary behavior, tone of voice, and physical gestures. But in many
forgetting. cases, only a few characteristics are distinct, because the
identities are only partially independent, so it is not true that
Generalized Amnesia – People who are
there are “multiple” complete personalities.
unable to remember anything, including who
they are. Lifelong or may extend from a period Alters – generally seemed to be another person
in the more recent past, such as 6 months or a entirely or separate identities.
year previously “host” identity – The person who becomes the
Localized or Selective Amnesia – a failure to patient and asks for treatment. Attempt to hold
recall specific events, usually traumatic, that various fragments of identity together but end up
occur during a specific period. being overwhelmed. The original personality.
Specify if: With dissociative fugue: Apparently Switch – transition from one personality to another,
purposeful travel or bewildered wandering that instantaneously.
is associated with amnesia for identity or for
other important autobiographical information. Diagnostic Criteria for Dissociative Identity Disorder
Dissociative amnesia is common during war Disruption of identity characterized by two or more
Dissociative Fugue (flight) [300.13 (F44.1)] – memory loss distinct personality states, which may be described
revolves around a specific incident—an unexpected trip (or in some cultures as an experience of possession.
trips). Mostly, individuals just take off and later find The disruption of marked discontinuity in sense of
themselves in a new place, unable to remember why or how self and sense of agency, accompanied by related
they got there. alterations in affect, behavior, consciousness,
memory, perception, cognition, and/or sensory-
Dissociative Trance – Sudden changes in personality motor functioning. These signs and symptoms may
accompany a trance or “possession”. Often associated with be observed by others or reported by the individual.
stress or trauma. Prevalent worldwide, usually in a religious Recurrent gaps in the recall of everyday events,
context; rarely seen in Western cultures. More common in important personal information, and/or traumatic
women than in men. events that are inconsistent with ordinary forgetting.
Dissociative amnesia seldom appears before adolescence The disturbance is not a normal part of a broadly
and usually occurs in adulthood. Dissociative amnesia is the accepted cultural or religious practice. Note: In
most prevalent of all the dissociative disorders children, the symptoms are not attributable to
imaginary playmates or other fantasy play.
Running disorders seem to resemble dissociative fugue:
Statistics
Amok – Western culture belief that individuals in this
trancelike state often brutally assault and sometimes Of people with DID, the ratio of females to males is
kill people or animals. If the person is not killed 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 The disturbance does not occur exclusively during
episodes of anorexia nervosa.
Psychological disruptions of two of our relatively
automatic behaviors, eating and sleeping, which Medical Consequences
substantially affect the rest of our behavior.
Salivary gland enlargement – repeated vomiting
MAJOR TYPES OF EATING DISORDER – the chief result to puff cheeks.
characteristic of these related disorders is an overwhelming, Electrolyte Imbalance – continued vomiting may
all-encompassing drive to be thin. upset the chemical balance of bodily fluids, including
sodium and potassium levels.
More than 90% of the severe cases are young
females who live in a socially competitive Cardiac arrhythmia (disrupted heartbeat), seizures,
environment. and renal (kidney) failure.
The strongest contributions to etiology of this Calluses on their fingers or the backs of their hands
disorder seem to be sociocultural caused by the friction of contact with the teeth and
throat.
Obesity – The more overweight someone is at a
given height, the greater the risks to health. Associated with anxiety and mood disorders.
Produced by the consumption of a greater number Anorexia nervosa [307.1] – the person eats nothing beyond
of calories than are expended in energy minimal amounts of food, so body weight sometimes drops
Bulimia Nervosa [307.51 (F50.2)] – out-of-control eating dangerously.
episodes, or binges, are followed by self-induced vomiting, Literally means a “nervous loss of appetite”—an
excessive use of laxatives, or other attempts to purge (get rid incorrect definition because appetite often remains
of) the food. healthy.
Typically, they eat more junk food than fruits and People with anorexia are proud of both their diets
vegetables—than most people would eat under and their extraordinary control. People with bulimia
similar circumstances. are ashamed of both their eating issues and their
Purging techniques – individual attempts to lack of control
compensate for the binge eating and potential Anorexia have an intense fear of obesity and
weight gain. (e.g. self-induced vomiting immediately relentlessly pursue thinness
after eating). has the highest mortality rate of any psychological
Purging Type – vomiting, laxatives, or disorder reviewed in this book, including depression.
diuretics. Significantly low weight – defined as a weight that
Nonpurging Type – excessive exercise is less than minimally normal or, for children and
and/or fasting. adolescents, less than that minimally expected.
Diagnostic Criteria for Bulimia Nervosa Two subtypes of anorexia nervosa – subtyping refer only
to the last 3 months.
Recurrent episodes of binge eating; eating, in a
discrete period of time (e.g., within any 2-hour Restricting type – individuals’ diet to limit calorie
period) and a sense of lack of control overeating intake. Not engaged in recurrent episodes of binge
during the episode (e.g., a feeling that one cannot eating or purging behavior.
stop eating or control what or how much one is Binge-eating–purging type – they rely on purging.
eating) Has engaged in recurrent episodes of binge eating
Recurrent inappropriate compensatory behavior in or purging behavior
order to prevent weight gain Diagnostic Criteria for Anorexia Nervosa
The binge eating and inappropriate compensatory
behaviors both occur, on average, at least once a Restriction of energy intake relative to requirements,
week for 3 months. leading to a significantly low body weight in the
Self-evaluation is unduly influenced by body shape context of age, sex, developmental trajectory, and
and weight. physical health.
Intense fear of gaining weight or of becoming fat, or episodes of *this disorder. The level of severity may be
persistent behavior that interferes with weight gain, increased to reflect other symptoms and the degree of
even though at a significantly low weight. functional disability.
Disturbance in the way in which one’s body weight
Mild: 1-3 episodes per week.
or shape is experienced, undue influence of body
Moderate: 4-7 episodes per week.
weight or shape on self-evaluation, or persistent lack
of recognition of the seriousness of the current low Severe: 8-13 episodes per week.
body weight. Extreme: 14 or more episodes per week
In partial remission: After full criteria for binge- Avoidant/Restrictive Food Intake Disorder [307.59
eating disorder were previously met, *the disorder (F50.8)] – An eating or feeding disturbance (e.g., apparent
occurs at an average frequency of less than one lack of interest in eating or food; avoidance based on the
episode per week for a sustained period of time. sensory characteristic of food; concern about aversive
In full remission: After full criteria for *the disorder consequences of eating) as manifested by persistent failure
disorder were previously met, none of the criteria to meet appropriate nutritional and/or energy needs.
have been met for a sustained period of time. Significant weight loss (or failure to achieve
Specify current severity (in Bulimia and Binge-eating): expected weight gain or faltering growth in children).
The minimum level of severity is based on the frequency of Significant nutritional deficiency.
Dependence on enteral feeding or oral nutritional Primary insomnia – sleep problems were not
supplements. related to other medical or psychiatric problems.
Marked interference with psychosocial functioning.
Diagnostic Criteria for Insomnia Disorder
SLEEP-WAKE DISORDERS – interrupts sleep
A predominant complaint of dissatisfaction with
Dyssomnia – involve difficulties in getting enough sleep, sleep quantity or quality
problems with sleeping when you want to (not being able to Difficulty initiating sleep
fall asleep until 2 a.m. when you have a 9 a.m. class), and Difficulty maintaining sleep, characterized
complaints about the quality of sleep, such as not feeling by frequent awakenings or problems
refreshed even though you have slept the whole night. returning to sleep after awakenings.
Note: In children, this may manifest as
Parasomnia – characterized by abnormal behavioral or
difficulty initiating sleep without caregiver
physiological events that occur during sleep, such as
intervention.
nightmares and sleepwalking.
The sleep difficulty occurs at least 3 nights per week.
ASSESSMENT OF SLEEP The sleep difficulty is present for at least 3 months.
The sleep difficulty occurs despite adequate
Polysomnographic (PSG) evaluation – evaluation
opportunity for sleep.
assesses an individual’s sleep habits with various electronic
Coexisting mental disorders and medical conditions
tests to measure airflow, brain activity, eye movements,
do not adequately explain the predominant
muscle movements, and heart activity. Results are weighed
complaint of insomnia.
with a measure of sleep efficiency (SE), the percentage of
Specify if:
time spent asleep.
Episodic: Symptoms last at least 1 month
Actigraph – records the number of arm movements, and the but less than 3 months.
data can be downloaded into a computer to determine the Persistent: Symptoms last 3 months or
length and quality of sleep. longer.
Recurrent: Two (or more) episodes within
Sleep efficiency (SE) – percentage of time actually spent
the space of 1 year.
asleep. To know the average number of hours the individual
sleeps each day. Hypersomnolence Disorders [780.54 (G47.10)] – involve
sleeping too much (hyper means “in great amount” or
SE of 100% – would mean you fall asleep as soon
“abnormal excess”). Excessive sleepiness that is displayed
as your head hits the pillow and do not wake up
as either sleeping longer than is typical or frequent falling
during the night. asleep during the day.
SE of 50% – would mean half your time in bed is
spent trying to fall asleep; that is, you are awake half Self-reported excessive sleepiness
the time. (hypersomnolence) despite a main sleep period
lasting at least 7 hours, with at least one of the
Daytime sequelae – determine whether a person has a following symptoms:
problem with sleep; behavior while awake.
Recurrent periods of sleep or lapses into
DYSSOMNIA – Disturbances in the timing, amount, or quality sleep within the same day.
of sleep. A prolonged main sleep episode of more
than 9 hours per day that is non-restorative
Insomnia Disorder [780.52 (G47.00)] – Difficulty falling (i.e., unrefreshing).
asleep at bedtime, problems staying asleep throughout the Difficulty being fully awake after abrupt
night, or sleep that does not result in the person feeling awakening
rested even after normal amounts of sleep. The hypersomnolence occurs at least three times
Microsleeps – a sleep that last several seconds or per week, for at least 3 months.
longer. Coexisting mental and medical disorders do not
Insomnia means “not sleeping,” adequately explain the predominance complaint of
hypersomnolence.
Specify if: showing a mean sleep latency less than or equal to
Acute: Duration of less than 1 month 8 minutes and two or more sleep-onset REM
Subacute: Duration of 1-3 months periods.
Persistent: Duration of more than 3 months Specify current severity:
Specify current severity: Mild: Infrequent cataplexy (less than once
Mild: Difficulty maintaining daytime per week), need for naps only once or twice
alertness 1-2 days/week per day, and less disturbed nocturnal sleep.
Moderate: Difficulty maintaining daytime Moderate: Cataplexy once daily or every
alertness 3-4 days/week few days, disturbed nocturnal sleep, and
Severe: Difficulty maintaining daytime need for multiple naps daily.
alertness 5-7 days/week Severe: Drug-resistant cataplexy with
multiple attacks daily, nearly constant
Narcolepsy – Episodes of irresistible attacks of refreshing sleepiness, and disturbed nocturnal sleep
sleep occurring daily, accompanied by episodes of brief loss (i.e., movements, insomnia, and vivid
of muscle tone (cataplexy). People with narcolepsy dreaming).
periodically progress right to this dream-sleep stage almost
directly from the state of being awake. BREATHE-RELATED SLEEP DISORDERS – A variety of
breathing disorders that occur during sleep and that lead to
Two characteristics distinguish people who have excessive sleepiness or insomnia. Sleepiness during the day
narcolepsy: or disrupted sleep at night has a physical origin. Problems
Sleep paralysis – brief period after awakening with breathing while asleep.
when they can’t move or speak that is often Sleep apnea – breathing is constricted that there
frightening to those who go through it. may be short periods (10 to 30 seconds) when they
Hypnagogic hallucinations – vivid and often stop breathing altogether.
terrifying experiences that begin at the start of sleep Sleep attacks – heavy sweating during the night,
and are said to be unbelievably realistic because morning headaches, and episodes of falling asleep
they include not only visual aspects but also touch, during the day with no resulting feeling of being
hearing, and even the sensation of body movement. rested.
(e.g. being caught in a fire)
Three Types of Apnea
Diagnostic Criteria for Narcolepsy
Obstructive sleep apnea hypopnea syndrome [327.23
Recurrent periods of an irrepressible need to sleep, (G47.33)] – occurs when airflow stops despite continued
lapsing into sleep, or napping occurring within the activity by the respiratory system. Polysomnography:
same day. These must have been occurring at least
three times per week over the past 3 months. Nocturnal breathing disturbances: snoring,
Episodes of cataplexy snorting/gasping, or breathing pauses during sleep.
In individuals with long-standing disease, Daytime sleepiness, fatigue, or unrefreshing sleep
brief (seconds to minutes) episodes of despite sufficient opportunities to sleep that is not
sudden bilateral loss of muscle tone with better explained by another mental disorder
maintained consciousness that are (including a sleep disorder) and is not attributable to
precipitated by laughter or joking. another medical condition
In children or in individuals within 6 months 15 or more obstructive apneas and/or hypopneas
of onset, spontaneous grimaces or jaw- per hour of sleep regardless of accompanying
opening episodes with tongue thrusting or a symptoms.
global hypotonia, without any obvious Specify current severity:
emotional triggers. Mild: Apnea hypopnea index is less than 15.
Hypocretin deficiency Moderate: Apnea hypopnea Index is 15-30.
Nocturnal sleep polysomnography showing rapid Severe: Apnea hypopnea index is greater than 30.
eye movement (REM) sleep latency less than or
equal to 15 minutes, or a multiple sleep latency test
Central sleep apnea – involves the complete cessation of each episode. There is relative unresponsiveness to efforts
respiratory activity for brief periods and is often associated of others to comfort the person during the episode.
with certain central nervous system disorders, such as
Sleepwalking – somnambulism; occurs during NREM sleep.
cerebral vascular disease, head trauma, and degenerative
Repeated episodes of rising from bed during sleep and
disorders.
walking about. While sleepwalking, the person has a blank,
Evidence by polysomnography of five or more staring face; is relatively unresponsive to the efforts of others
central apneas per hour of sleep. to communicate with him or her; and can be awakened only
with great difficulty.
Sleep-related hypoventilation – decrease in airflow without
a complete pause in breathing. This tends to cause an Non-Rapid Eye Movement Sleep Arousal Disorders –
increase in carbon dioxide (CO2) levels, because insufficient Recurrent episodes of incomplete awakening from sleep
air is exchanged with the environment. usually occurring during the first third of the major sleep
episode.
Circadian Rhythm Sleep Disorder – A discrepancy
between the sleep–wake schedule required by a person to Sleep terror and sleepwalking
be rested and the requirements of the person’s environment No or little (e.g., only a single-visual-scene) dream
(e.g., work schedules) that leads to excessive sleepiness or imagery is recalled.
insomnia. Amnesia for the episodes is present.
Characterized by disturbed sleep brought on by the Nightmares (or nightmare disorder) [307.47 (F51.5)] –
brain’s inability to synchronize its sleep patterns with occur during REM or dream, sleep terrors, and incomplete
the current patterns of day and night. awakening. Repeated occurrences of extended, extremely
Jet lag type – rapidly crossing multiple time zones dysphoric, and well-remembered dreams that usually involve
Shift work type – people work at night or must work efforts to avoid threats to survival, security or physical
irregular hours; as a result, they may have problems integrity and that generally occur during the second half of
sleeping or experience excessive sleepiness during the major sleep episode.
waking hours.
Specify current severity: Severity can be rated by the
Delayed sleep phase type – Extreme night owls,
frequency with which the nightmares occur:
people who stay up late and sleep late.
Mild: Less than one episode per week on average
Advanced sleep phase type – “early to bed and
Moderate: One or more episodes per week but less
early to rise.”
than nightly
irregular sleep–wake type – people who Severe: Episodes nightly
experience highly varied sleep cycles.
non-24-hour sleep–wake type – sleeping on a 25- Rapid Eye Movement Sleep Behavior Disorder [327.42
or 26-hour cycle with later and later bedtimes (G47.52)] – Repeated episodes of arousal during sleep
ultimately going throughout the day associated with vocalization and/or complex motor
Specify if: behaviors. These behaviors arise during rapid eye movement
Episodic: Symptoms last at least 1 month but less (REM) sleep and therefore usually occur greater than 90
than 3 months. minutes after sleep onset, are more frequent during the later
Persistent: Symptoms last 3 months or longer. portions of the sleep period, and uncommonly occur during
Recurrent: Two or more episodes occur within the daytime naps.
space of 1 year. Upon awakening from these episodes, the individual is
PARASOMNIAS – Abnormal behaviors that occur during completely awake, alert, and not confused or disoriented.
sleep.
REM sleep without atonia on polysomnographic
Sleep Terrors – Recurrent episodes of abrupt terror arousals recording.
from sleep, usually beginning with a panicky scream. There A history suggestive of REM sleep behavior disorder
is intense fear and signs of autonomic arousal, such as and an established synucleinopathy diagnosis (e.g.,
mydriasis, tachycardia, rapid breathing, and sweating, during 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:
Sadistic Rape – After murder, rape is the most devastating 1. A strong desire to be of the other gender or an
assault one person can make on another. many rapists meet insistence that one is the other gender.
criteria for antisocial personality disorder. 2. In boys, a strong preference for cross-dressing or
simulating female attire: or in girls, a strong
Sexual Masochism Disorders [302.83 (F65.51)] – suffering preference for wearing only typical masculine
pain or humiliation and becoming sexually aroused is clothing and a strong resistance to the wearing of
specifically associated with violence and injury in these typical feminine clothing.
conditions. Specify if: 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
Impulse-control disorders – represent a number of related Mild – the person exhibits only two or three of the 11
problems that involve the inability to resist acting on a drive criteria met. (substance use results in a failure to
or temptation. (impulse to steal or to set fire) fulfill major role obligations)
Moderate – four or five criteria met
LEVELS OF INVOLVEMENT
Severe – six or more criteria met. (occupational or
Substance – refers to chemical compounds that are ingested recreational activities are given up or reduced
to alter mood or behavior. because of substance use)
Safe/Legal drugs – also affect mood and behavior, they can Depressants: These substances result in behavioral
be addictive. (e.g. alcohol, the nicotine found in tobacco, and sedation and can induce relaxation. They include alcohol
the caffeine in coffee, soft drinks, and chocolate.) (ethyl alcohol) and the sedative and hypnotic drugs in the
families of barbiturates (for example, Seconal) and
Substance Use – ingestion of psychoactive substances in benzodiazepines (for example, Valium, Xanax).
moderate amounts that does not significantly interfere with
social, educational, or occupational functioning. Stimulants: These substances cause us to be more active
and alert and can elevate mood. Included in this group are
Substance Intoxication – physiological reaction to ingested amphetamines, cocaine, nicotine, and caffeine.
substances—drunkenness or getting high.
Opiates: The major effect of these substances is to produce
Substance abuse – how much of a substance is ingested is analgesia temporarily (reduce pain) and euphoria. Heroin,
problematic. How significantly it interferes with the user’s life opium, codeine, and morphine are included in this group.
such disrupt your education, job, or relationships with others,
and put you in physically dangerous situations. Hallucinogens: These substances alter sensory perception
and can produce delusions, paranoia, and hallucinations.
Substance Dependence (Addiction) – the person is Cannabis and LSD are included in this category.
physiologically dependent on the drug or drugs.
Other Drugs of Abuse: Other substances that are abused
Tolerance – requires increasingly greater amounts but do not fit neatly into one of the categories here include
of the drug to experience the same effect. inhalants (for example, airplane glue), anabolic steroids, and
Withdrawal – respond physically in a negative way other over-the-counter and prescription medications (for
when the substance is no longer ingested. example, nitrous oxide). These substances produce a variety
Withdrawal from many substances can bring on headache, of psychoactive effects that are characteristic of the
chills, fever, diarrhea, nausea and vomiting, and aches and substances described in the previous categories.
pains. Even hallucinations and body tremors in alcohol. Gambling Disorder: As with the ingestion of the substances
Cocaine withdrawal has a pattern that includes just described, individuals who display gambling disorder are
anxiety, lack of motivation, and boredom unable to resist the urge to gamble which, in turn, results in
negative personal consequences (e.g., divorce, loss of
Cannabis withdrawal includes such symptoms as
employment).
nervousness, appetite change, and sleep
disturbance
Criteria present across all substance-related disorder. The Clinically significant problematic behavioral or
underline indicates the disorder. psychological changes that developed during, or
shortly after, ______ ingestion.
A problematic pattern of ______ leading to clinically
One (or more) of the following signs or symptoms
significant impairment or distress, as manifested by
developing during, or shortly after, ______ use:
at least two of the following, occurring within a 12-
month period Criteria present across all withdrawal related in every
______ is often taken in larger amounts or over a disorder.
longer period than was intended.
Cessation of (or reduction in) _____ use that has
There is a persistent desire or unsuccessful efforts
been heavy and prolonged.
to cut down or control _____ use.
Two (or more) of the following, developing within
A great deal of time is spent in activities necessary
several hours to a few days:
to obtain alcohol, use ___, or recover from its effects.
Craving, or a strong desire or urge to use ______. DEPRESSANTS – decrease central nervous system activity.
Recurrent alcohol use resulting in a failure to fulfill Included in this group are alcohol and the sedative, hypnotic,
major role obligations at work, school, or home. (e.g. and anxiolytic drugs, such as those prescribed for insomnia.
repeated absences from work or poor work
Alcohol-Related Disorders
performance related. Absences, suspensions, or
expulsions from school; neglect of children or Alcohol Use Disorder – (the criteria for this disorder is given
household.) on the “Criteria present across all substance-related disorder.
Continued _____ use despite having persistent or The underline indicates the disorder.”
recurrent social or interpersonal problems caused or
exacerbated by the effects of alcohol. Alcohol Intoxication – Slurred speech, Incoordination,
Unsteady gait, Nystagmus, Impairment in attention or
Important social, occupational, or recreational
memory, Stupor or coma. Inappropriate sexual or aggressive
activities are given up or reduced because of __ use.
behavior, mood lability, impaired judgment.
Recurrent _____ use in situations in which it is
physically hazardous. Alcohol Withdrawal – Autonomic hyperactivity (e.g.,
______ use is continued despite knowledge of sweating or pulse rate greater than 100 bpm). Increased
having a persistent or recurrent physical or hand tremor. Insomnia. Nausea or vomiting. Transient visual,
psychological problem that is likely to have been tactile, or auditory hallucinations or illusions. Psychomotor
caused or exacerbated by ______. agitation. Anxiety. Generalized tonic-clonic seizures.
Tolerance and Withdrawal
Specify if: With perceptual disturbances: This
Specify if: specifier applies in the rare instance when
hallucinations (usually visual or tactile) occur with
In early remission: After full criteria for alcohol use
intact reality testing, or auditory, visual, or tactile
disorder were previously met, none of the criteria for
illusions occur in the absence of a delirium.
alcohol use disorder have been met for at least 3
months but for less than 12 months (with the Sedative-, Hypnotic-, or Anxiolytic-Related Disorders –
exception that bullet no. 4). sedative (calming), hypnotic (sleep-inducing), and anxiolytic
In sustained remission: After full criteria for alcohol (anxiety-reducing) drugs.
use disorder were previously met, none of the
Barbiturates – (which include Amytal, Seconal, and
criteria for alcohol use disorder have been met at
Nembutal) are a family of sedative drugs.
any time during a period of 12 months or longer (with
the exception that bullet no. 4). Benzodiazepines – (which today include Valium,
Xanax, and Ativan) primarily to reduce anxiety.
Criteria present across all intoxication related in every
disorder: Sedative, Hypnotic, or Anxiolytic Intoxication – same as
alcohol intoxication criteria
Recent ingestion of ___
Sedative, Hypnotic, or Anxiolytic Withdrawal – same as
alcohol withdrawal criteria
STIMULANTS Caffeine-Related Disorder – Caffeine called the “gentle
stimulant” because it is thought to be the least harmful of all
Stimulant Use Disorder – the criteria for this disorder is
addictive drugs. Found in tea, coffee, many cola drinks sold
given on the “Criteria present across all substance-related
today, and cocoa products.
disorder. The underline indicates the disorder.”
Caffeine Intoxication – Recent consumption of caffeine
Amphetamines – can induce feelings of elation and vigor
(typically a high dose well in excess of 250 mg). Five (or
and can reduce fatigue. Amphetamines are prescribed for
more) of the following signs or symptoms developing during,
people with narcolepsy. also reduce appetite; lose weight.
or shortly after, caffeine use: Restlessness. Nervousness.
“boost” and stay awake. Significant behavioral symptoms,
Excitement. Insomnia. Flushed face. Diuresis.
such as euphoria or affective blunting (a lack of emotional
Gastrointestinal disturbance. Muscle twitching. Rambling
expression), changes in sociability, interpersonal sensitivity,
flow of thought and speech. Tachycardia or cardiac
anxiety, tension, anger, stereotyped behaviors, impaired
arrhythmia. Periods of inexhaustibility and Psychomotor
judgment, and impaired social or occupational functioning.
agitation.
Cocaine – derived from the leaves of the coca plant, a
Caffeine Withdrawal – Headache. Marked fatigue or
flowering bush indigenous to South America. increases
drowsiness. Dysphoric mood, depressed mood, or irritability.
alertness, produces euphoria, increases blood pressure and
Difficulty concentrating. Flu-like symptoms (nausea,
pulse, and causes insomnia and loss of appetite.
vomiting, or muscle pain/stiffness).
Cocaine-induced paranoia – experiencing OPIOIDS – family of substances that includes natural
exaggerated fears that he would be caught or that opiates, synthetic variations (heroin, methadone,
someone would steal his cocaine. hydrocodone, oxycodone), and the comparable substances
Stimulant Intoxication – Tachycardia or bradycardia. that occur naturally in the brain (enkephalins, beta-
Pupillary dilation. Elevated or lowered blood pressure. endorphins, and dynorphins).
Perspiration or chills. Nausea or vomiting. Evidence of weight
Opiate – refers to the natural chemicals in the opium
loss. Psychomotor agitation or retardation. Muscular
poppy that have a narcotic effect (they relieve pain
weakness, respiratory depression, chest pain, or cardiac
and induce sleep). Induce euphoria, drowsiness,
arrhythmias. Confusion, seizures, dyskinesias, dystonia, or
and slowed breathing.
coma.
Opioid Use Disorder – The criteria for this disorder is given
Specify if: With perceptual disturbances on the “Criteria present across all substance-related disorder.
Stimulant Withdrawal – Fatigue. Vivid, unpleasant dreams. The underline indicates the disorder.”
Insomnia or hypersomnia. Increased appetite. Psychomotor Opioid Intoxication – initial euphoria followed by apathy,
retardation or agitation. dysphoria, psychomotor agitation or retardation, impaired
Tobacco Use Disorder – cigarette smoking. The criteria for judgment. Pupillary constriction (or pupillary dilation due to
this disorder is given on the “Criteria present across all anoxia from severe overdose). Drowsiness or coma. Slurred
substance-related disorder. The underline indicates the speech. Impairment in attention or memory. Specify if: With
disorder.” perceptual disturbances.
Nicotine – is inhaled into the lungs, where it enters the Opioid Withdrawal – Administration of an opioid antagonist
bloodstream and reaches the brain and appears to stimulate after a period of opioid use. Dysphoric mood. Nausea or
nicotinic acetylcholine receptors (nAChRs)—in the midbrain vomiting. Muscle aches. Lacrimation or rhinorrhea. Pupillary
reticular formation and the limbic system, the site of the dilation, piloerection, or sweating. Diarrhea. Yawning. Fever.
brain’s pleasure pathway. Insomnia.