LEARNING DSM-5 BY CASE EXAMPLE by Michael B. First, Andrew E. Skodol

With at least one case presentation for each of the mental disorders catalogued in DSM-5 -- and multiple cases for nearly half of the disorders -- Learning DSM-5(R) by Case Example has been meticulously designed to aid practitioners and students of all levels in psychology, psychiatry, social work, counseling, and psychiatric nursing develop internalized prototypes of DSM-5 disorders by first describing each disorder in relatable terms and subsequently illustrating how these symptom constellations manifest in real-life settings using clinical case material.

The nearly 200 cases featured in this guide are drawn from the authors' own clinical experience, as well as that of well over 100 clinicians, many of whom are well-known experts in particular areas of diagnosis and treatment. Sensitive to the fact that one of the hallmarks of mental disorders is the wide range of presentations that are encountered in a real-world setting, many of the disorders described include multiple cases that vary in symptom presentation, gender, age, clinical course, associated impairment in psychosocial functioning, and developmental factors, thus giving readers an appreciation for the heterogeneity typical of these disorders. Each case is complemented by a discussion that elaborates the ways in which the case conforms to the DSM-5 prototype or highlights those features of the case that illustrate the heterogeneity.

With definitions of potentially unfamiliar medical and psychiatric terms, Learning DSM-5(R) by Case Example is an accessible resource for readers of all disciplines. And because it guides the reader through the organizational structure of DSM-5, it is also an ideal reference for courses on psychopathology or abnormal psychology. - Learning DSM-5 by Case Example 1st Edition

Introduction
Chapter 1. Neurodevelopmental Disorders.
CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders
CHAPTER 3 Bipolar and Related Disorders
CHAPTER 4 Depressive Disorders
CHAPTER 5 Anxiety Disorders
CHAPTER 6 Obsessive-Compulsive and Related Disorders
CHAPTER 7 Trauma- and Stressor- Related Disorders
CHAPTER 8 Dissociative Disorders
CHAPTER 9 Somatic Symptom and Related Disorders
CHAPTER 10 Feeding and Eating Disorders
CHAPTER 11 Elimination Disorders
- 11.1 Enuresis
- 11.2 Encopresis
CHAPIER 12 Sleep-Wake Disorders
CHAPTER 13 Sexual Dysfunctions
CHAPTER 14 Gender Dysphoria
- 14.1 Gender Dysphoria in Children
- 14.2 Gender Dysphoria in Adolescents
CHAPTER 15 Disruptive, Impulse-Control, and Conduct Disorders
CHAPTER 16 Substance-Related and Addictive Disorders
CHAPTER 18 Personality Disorders
CHAPTER 19 Paraphilic Disorders

Introduction

Introduction

Purpose:

Helps students learn DSM-5 diagnoses using case examples
Accelerates development of clinical prototypes
Describes each disorder in prototype terms and illustrates presentations in real cases

Case Selection:

Includes cases from various disciplines: psychology, psychiatry, social work, counseling, nursing
Represents diagnostic heterogeneity for many disorders
Does not include separate cases for Mental Disorders Due to Another Medical Condition or Substance/Medication-Induced Mental Disorders, as their presentations are conceptually the same and differ only in terms of symptoms and causative agents. However, some representative cases are included: Catatonic Disorder Due to Another Medical Condition, Depressive Disorder Due to Another Medical Condition, Anxiety Disorder Due to Another Medical Condition, Major Neurocognitive Disorder Due to Another Medical Condition, Personality Change Due to Another Medical Condition, Methylphenidate-Induced Psychotic Disorder, Alcohol-Induced Psychotic Disorder, Ofloxacin-Induced Bipolar and Related Disorder, Caffeine/Aminophylline/Albuterol/Beclomethasone-Induced Sleep Disorder, Paroxetine-Induced Sexual Dysfunction, Alcohol Withdrawal Delirium, and Alcohol-Induced Major Neurocognitive Disorder.

Diagnostic Approach:

Clinicians often make diagnoses based on matching symptoms to internalized prototypes rather than applying diagnostic criteria systematically
This book aims to create these clinical prototypes by describing each DSM-5 disorder in prototype terms and illustrating presentations in real cases

Case Organization:

Cases are organized according to the order of diagnostic groupings as they appear in DSM-5
Some chapters rearrange the order for educational purposes.

Intended Audience:

Primarily designed for students, but also useful for experienced clinicians, other professionals, and historically interested readers
Includes an alphabetical index of diagnoses to help readers find cases based on DSM-5 diagnosis given.

Chapter 1. Neurodevelopmental Disorders.

INTELLECTUAL DISABILITIES.

1.1 Intellectual Disability (Intellectual Developmental Disorder)

Neurodevelopmental Disorders: Intellectual Disabilities

Intellectual Disability (Intellectual Developmental Disorder)

Characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience
Impairments of adaptive functioning, including personal independence and social responsibility in various aspects of daily life (communication, social participation, academic or occupational functioning, personal independence)
Diagnosis based on clinical assessment and individually administered, psychometrically valid IQ tests with scores approximately two standard deviations below the population mean
Adaptive functioning involves three domains: conceptual (academic), social, and practical

Characteristics of Intellectual Disability:

Deficits in intellectual functions
Difficulties in acquisition and use of language
Interference with speech intelligibility or prevention of verbal communication
Disturbance in normal fluency and time patterning of speech
Difficulties in social use of verbal and nonverbal communication
Restricted, repetitive patterns of behavior, interests, or activities
Patterns of inattention and/or hyperactivity-impulsivity
Some symptoms present prior to age 12 years
Present in two or more settings (home, school, work, friends, relatives, other activities)
Difficulties learning and using academic skills
Acquisition and execution of coordinated motor skills substantially below expected age level
Repetitive, driven, and seemingly purposeless motor behavior
Sudden, rapid, recurrent, nonrhythmic motor movement or vocalization

Intellectual Disability:

Affects 1% of the general population
Males more likely to be affected than females
Deficits have an onset during the developmental period but may not be present at birth
Causes: genetic (Down syndrome), illnesses (meningitis, encephalitis, head trauma) or acquired
Levels of severity: mild, moderate, severe, or profound based on adaptive functioning in conceptual, social, and practical domains
Global Developmental Delay is a diagnosis for individuals under age 5 who cannot be reliably assessed for intellectual disability severity level.

Down Syndrome

Case Study: Eric's Behavioral Issues

Background:

Eric, a 15-year-old boy with Down Syndrome (DS)
Parents divorced for 4 years, father lives in another city
Previous residential placements since age 8 due to intellectual impairments and behavioral issues
Mother brought him home 6 months ago, but he was destructive and aggressive towards her during this time

Symptoms:

Destructive of property: breaking dishes, chair
Physically assaultive: hit mother during scuffles
Increasing behavior problems since birth
Signs of Down Syndrome: thick facial features, slightly protruding tongue, epicanthal fold, simian crease on palms
Indistinct and slurred speech
Insisted he "didn't mean to hurt anybody"

Diagnosis:

Intellectual Disability (ID) due to Down Syndrome:
- Significant deficits or impairments in adaptive functioning
- IQ of 45 indicates general intellectual functioning deficits
- Diagnose regardless of other diagnoses
Down Syndrome:
- Additional diagnosis alongside ID
- Causes Intellectual Disability since birth
Possible Diagnosis: Conduct Disorder (CD)
- Not justified due to lack of characteristic features
Presenting issue is destructive and aggressive behavior, not intellectual functioning impairment.

The Enigma

The Enigma

Psychiatrist's Consultation:

Psychiatrist received a call from a pediatric colleague about 17-year-old Libby
Described as "cured from depression" and needing only follow-up medication
Arrival at the clinic was marked by her agitated, restless behavior and high-pitched unintelligible screaming

Patient Profile:

Diagnosed with severe mental retardation under 1 year of age
Extensive diagnostic evaluations failed to determine the etiology of her intellectual deficits
Physically healthy, only child, reared at home, attended special classes in public schools
Cheerful, friendly, and affectionate, nonverbal but communicated through gestures and vocalizations
Learned household tasks, helped mother around the house
Previously cheerful demeanor changed 6 months ago when parents went on a weeklong vacation
Became agitated, unresponsive, cried frequently, slept poorly, ate little, spent time aimlessly roaming the house
Parents felt guilty and tried to make amends by spending all their time with her
Attempted to give her attention and affection, but this only made matters worse
Pediatrician gave her an antianxiety drug, which had no effect

Previous Treatments:

School psychologist thought her behavior was an attention-getting device, so referred the family to a child guidance clinic
Child psychiatrist suggested giving Libby unlimited attention and affection, but this also made matters worse
Another psychiatrist diagnosed her as depressed and prescribed antidepressant medication, which also did not improve her condition
Libby was hospitalized on a pediatric ward, where extensive medical evaluation failed to disclose the cause of her condition

Current Treatment:

Pediatrician treated Libby for "psychotic depression" and increased the antidepressant medication and added an antipsychotic drug
This led to some improvement, but she suffered a relapse and needed to be hospitalized again
Family history revealed that a maternal aunt suffered from depression and responded well to lithium treatment
Libby was started on lithium, which gradually improved her condition and allowed the antipsychotic medication to be discontinued

Discussion:

Difficulty in diagnosing people with Severe Intellectual Disability who are unable to describe their subjective experiences
Libby's behavior was dismissed as a "nonspecific behavior disorder" or "exhibition of attention-getting behaviors due to overprotection by parents"
Her clinical presentation was dominated by irritable mood, agitation, distractibility, and sleep disturbance - all of which are included in the diagnostic criteria for Manic Episode
Symptoms such as grandiosity, flight of ideas, and excessive involvement in pleasurable activity could not be described by a severely intellectually challenged and nonverbal person
The clinical presentation was cyclic, with periods of crying, decreased activities, loss of appetite, and insomnia - all suggestive of Major Depressive Disorder
Family history was positive for a lithium-responding "depression," suggesting Libby may have been in a Major Depressive Episode when put on the antidepressant medication, which then triggered manic symptoms

COMMUNICATION DISORDERS

1.2 Language Disorder

Language Disorder (LD)

Characterized by persistent difficulties in language acquisition and use across modalities due to deficits in comprehension or production (DSM-5, p. 42)

Symptoms:

Reduced vocabulary
Limited sentence structure
Impairment in discourse
Difficulties not age-appropriate
Interferes with social and academic functioning
Not due to hearing problems, motor dysfunctions, other medical or neurological conditions, or Intellectual Disability

Types:

Expressive abilities (production of verbal material)
Receptive abilities (understanding of language messages)
Both expressive and receptive abilities

Prognosis:

Language Disorder present at age 4 years likely to persist into adulthood
Children with receptive language impairments have a poorer prognosis than those with only expressive problems

Case Studies:

Don:
- Born 11 weeks premature with hyaline membrane disease
- Complicated medical history including bilateral hernia repairs
- Developmental milestones within normal limits until age 3 years and 7 months
- Slow to warm up during examination
- Extremely difficult to understand, had to use gestures for clarification
- Most sentences consisted of single words or mispronounced speech (e.g., "dub" instead of "gun")
- Limited vocabulary (e.g., "fish" = "pet")
- Could follow commands and produce drawings sophisticated for age
- No difficulty understanding language, suggestive of expressive type LD
Zach:
- Evaluated due to problems in school
- Difficulties getting along with children and teacher throughout kindergarten
- Improvement seen recently with play skills but still had trouble understanding instructions and expressing himself verbally
- Quiet and shy during examination, mother had to remain in the room for support
- Limited verbalizations (only told examiner his name)
- Inappropriate responses during tasks, unclear grasp of task purpose
- Absence of bizarre behavior rules out Autism Spectrum Disorder
- Diagnosis: Language Disorder involving both reception and expression.

1.3 Speech Sound Disorder

Speech Sound Disorder (SSD)

Characteristic feature: persistent difficulty with speech sound production that interferes with intelligibility or prevents verbal communication
Interferes with social activities and academic achievement
Not caused by congenital or acquired conditions, such as cleft palate, cerebral palsy, hearing loss, or traumatic brain injury
Onset in early developmental period
Most children have intelligible speech by age 3 and speak most words correctly by age 7
Speech problems usually improve with treatment

Diagnosis of SSD:

André, a 6-year-old, exhibits difficulty articulating various sounds, particularly r, l, and th (among the later-acquired speech sounds)
Normal intelligence and social development rule out other disorders:
- Language Disorder
- Intellectual Disability (Down Syndrome)
- Autism Spectrum Disorder

Additional Diagnosis:

Frequent letter reversals may raise question for an additional diagnosis of Specific Learning Disorder, With Impairment in Written Expression
However, some letter reversals are normal at age 6 and this diagnosis is given only if test reveals scores significantly below expected level.

1.4 Childhood-Onset Fluency Disorder (Stuttering)

Childhood-Onset Fluency Disorder (Stuttering)

Characterized by persistent disturbances in normal fluency and time patterning of speech for individuals' age and language skills (DSM-5, p. 45)
Hallmarks: sound and syllable repetitions, prolongations, pauses, circumlocutions, physical tension during speech, monosyllabic whole-word repetition
Severe enough to interfere with social or academic functioning
Not caused by speech-motor or sensory deficits or neurological problems
Commonly referred to as stuttering
Absent during activities like reading aloud, singing, talking to pets, or inanimate objects (DSM-5, p. 45)
Onset in childhood, with most cases developing by age 6; majority recover by age 8

Case Study: "Don't Worry"

Parents noticed Aaron's stuttering several months earlier
Initially rare occurrences became more frequent and caused frustration and anxiety for the child
Speech therapist suggested maintaining composure during episodes and not completing sentences
Over time, stuttering gradually resolved, leaving no permanent emotional scars or speech difficulties (DSM-5, p. 45)
Variable severity from situation to situation, more severe under pressure to communicate.

1.5 Social (Pragmatic) Communication Disorder

Social (Pragmatic) Communication Disorder

Defined as "persistent difficulties in the social use of verbal and nonverbal communication" (DSM-5, p. 47)
New diagnostic label added to describe individuals who have social communication component of Autism Spectrum Disorder but do not meet restricted behavior criterion
Social communication essential for social participation, development of relationships, academic achievement, occupational performance
Characteristic deficits: inability to share information appropriately; difficulty changing style of communication to match context or listener needs; trouble following conversation rules (taking turns); understanding idioms, humor, metaphors dependent on context
Problems interfere with social relationships or academic/occupational functioning
Not due to neurological conditions or other mental disorders (Intellectual Disability, Autism Spectrum Disorder, Global Developmental Delay)
Children ages 4-5 should participate in social communication appropriately; onset may not be apparent until early adolescence
Outcome variable; some improve significantly over time, others persist into adulthood

Case Study: Clifford's Social Communication Difficulties

Age 13, seventh-grade student with delayed language development
Late talker, received speech therapy from preschool to third grade for delayed use of language and difficulties with sibilant sounds
Continues to have some verbal communication difficulties: talks loudly despite reminders; talks over others in small groups; pedantic when excited about topics; difficulty following conversations
Favorite subjects are math and computer-related things; interests limit social interactions with peers
Has few close friends, considers online contacts as friends; difficult reading body language or nonverbal cues
Insensitive to feelings of peers, repeats hurtful behaviors without understanding impact
Persistent difficulties in the social use of verbal and nonverbal communication interfere with peer group interactions and cause impairment in social functioning.

Social Gaffes Behavior

Difficulty communicating with friends in conversation; talks over them about irrelevant topics
Inability to modulate conversational tone (talks loudly, pedantically)
Talks on and on without regard for others in the conversation
Hurtful words or actions due to lack of understanding social cues and body language
Poor at interpreting jokes that depend on context.

AUTISM SPECTRUM DISORDER

1.6 Autism Spectrum Disorder

Autism Spectrum Disorder (ASD)

New diagnosis in DSM-5, characterized by:
- Persistent deficits in social communication and interaction across multiple contexts
- Restricted, repetitive patterns of behavior, interests, or activities
Subsumes most cases of DSM-IV Autistic Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder Not Otherwise Specified (PDNOS)

Social Communication Deficits:

Deficits in social-emotional reciprocity: Limited back-and-forth conversation or sharing of interests and feelings
Deficits in nonverbal communication: Poor eye contact, lack of facial expression, misunderstanding or use of gestures
Deficits in developing, maintaining, and understanding relationships: Difficulties adjusting behavior to social context, poor peer relations, lack of interest in peers

Restricted Patterns:

Stereotyped motor movements, objects, or speech (e.g., lining up toys, flipping objects, echoing)
Ineflexible adherence to daily routines
Pathological resistance to change (distress at small changes)
Ritualized behaviors (repetitive questioning, pacing)
Highly restricted and fixated interests (e.g., strong attachment to objects, preoccupation with vacuums)
Abnormal responses to sensory input: extreme reactions to sounds or textures, excessive smelling/touching, fascination with lights or spinning objects, indifference to pain, heat, or cold
Savant abilities in areas like art, music, calendar calculation, math, and spatial skills (fewer than 10% of individuals have such abilities)

Diagnosis and Severity:

Signs typically become evident between ages 12-24 months but may not fully manifest until social demands exceed child’s capacities
Social, occupational functioning adversely affected
Severity level based on deficits in social communication and restricted behaviors:
- Level 1: Requiring support
- Level 2: Requiring substantial support
- Level 3: Requiring very substantial support

Variability:

With or Without Accompanying Intellectual Impairment
With or Without Accompanying Language Impairment
Associated With a Known Medical or Genetic Condition or Environmental Factor
Associated With Another Neurodevelopmental, Mental, or Behavioral Disorder

Prevalence:

Estimated at 1% worldwide
Rates have risen due to expanded definitions, increased awareness, true increase in incidence, or a combination of factors
Diagnosed four times more often in boys than girls; girls may go unrecognized if without Intellectual Disability
Course is usually toward improvement over time, but only a minority live and work independently.

Echo

Reed's Developmental Delay and Abnormal Behavior

Background:

Firstborn child
Difficult delivery, needed oxygen at birth
Lack of response to social contact and baby games from infancy

Physical Development:

Age-appropriate in terms of appearance, motor skills, self-help skills

Concerns:

Self-absorbed and aloof from others
No interest in other children or communication with siblings
Lack of facial expressions, gestures, or mime to express needs
Intense attachment to a miniature car
Limited repertoire of spontaneous activities: collecting kitchen utensils, assembling puzzles, aimless running around

Behavioral Patterns:

Resistance to change or extension of interests
Tantrums during attempts to change routines
Effective coping mechanisms: playing favorite music or taking long car rides

Diagnostic Indications:

Possible deafness ruled out due to love of music and sensitivity to sounds
Psychological testing showed impairment in social interaction, communication, and restricted activities (DSM-5, p. 50)

Symptoms:

Marked impairment in reciprocal social interaction
Limited verbal communication with echoing words and phrases
Absence of imaginative play
Stereotyped motor mannerisms and interests.

The Roman

Ronald's Case Study

Background:

Roman, a 19-year-old man from London
Youngest of four children with older siblings who were intelligent and well-adjusted
Difficult birth and episodes of cyanosis in first 48 hours
Delayed motor and language development but not enough to warrant concern at the time
Quiet, self-contained baby and child, never initiated play but did as told
No apparent problems, but lacked imaginative pretend play

Developmental Milestones:

Poorly coordinated in gross motor movements (rolling over, sitting up)
Slow learner in dressing himself and performing other motor tasks
Spoke very little but responded to questioning with grammatical speech
Odd vocal intonation, spaced rises and falls in speech, avoided eye contact

Behavioral Patterns:

Walked the same school route daily, insisted on sitting in same seat
Organized desk and books precisely
Coped with schoolwork due to good rote memory and reading skills
Poor at arithmetic, did less well in all subjects as abstract ideas were demanded
Naive and immature, protected from bullying by older siblings
No real friends outside family

Interests:

Learned to read before school age through TV commercials
Began reading about ancient Romans and archaeological remains at around 7 years old
Amassed prodigious knowledge on ancient Rome but lacked deeper understanding of historical context
Spent all spare time pursuing Roman interests, alienating some peers

Diagnosis:

Autism Spectrum Disorder based on long history of odd social behaviors since early childhood
Social communication skills impairment at mildest level (requiring support)
Restricted patterns of interests and activities, suggesting diagnosis of Autism Spectrum Disorder

Additional Information:

Diagnosis encompassed by DSM-5's Autism Spectrum Disorder instead of separate Asperger’s Syndrome diagnosis in prior edition.

Rocking and Reading

Betsy's Case

Background:

Betsy, 22 years old, referred for evaluation after "not fitting in" at group home
Placed in residential treatment at age 4, remained there since
Parents both deceased, no contact with sibling
Reported to have several abnormal electroencephalograms but no seizures or medical problems
IQ of 55, comparable deficits in adaptive behaviors

Evaluation Findings:

Spent time reading children's book, monotonic voice, unable to respond to questions about it
Repeated single phrase "Blum, blum" in a monotonic voice
Continuous rocking during interview, made eye contact initially but otherwise oblivious of surroundings
No initiation of activities, lack of response to examiner's attempts to interest her
Self-abusive behavior: repeated pounding of legs, biting hand
Physical examination revealed extensive bruises on lower extremities

Early Childhood History:

Delayed motor milestones, concerns about hearing
Unusual ability to memorize and fascination with reading despite lack of comprehension
Repetitive stereotyped behaviors: body rocking, head banging
Lack of attachments to parents, idiosyncratic responses to sounds
Extreme upset when there were changes in environment

Diagnosis:

Autism Spectrum Disorder (DSM-5): impairment in social interaction, abnormal speech, repetitive stereotyped behaviors, restricted range of interests
Stereotypic Movement Disorder: self-injurious behavior, severe enough to be a focus of treatment
Intellectual Disability (DSM-5): accompanying limitation to independent function
Previous diagnosis of Childhood Schizophrenosis not relevant due to lack of continuity with adult psychosis.

Reggie’s Regression

Reggie's Case

Reggie's Background:

Born to professional parents
Normally sociable baby, developed normally up to age 3
Enrolled in nursery school and toilet trained at that time
Parents had videotapes showing normal development

Regression:

Around the birth of a sibling, Reggie became anxious and agitated
Over several weeks, his behavior regressed markedly in:
- Toilet training
- Age-appropriate self-care activities
- Social skills
- Spending hours rocking back and forth
By age 4, Reggie was functioning at a 1-year level in cognitive and communicative abilities
Exhibited behavioral features suggestive of autism (lack of social responsivity, difficulties with transitions, stereotyped movements)

Evaluation Findings:

No specific medical condition identified from extensive medical evaluations
Reggie was enrolled in a special education program with full-time aide and educational supports by age 6
Despite the supports, Reggie made few developmental gains and remained almost entirely mute

Discussion:

Reggie's case is characterized by severe impairment in language and social reciprocity, and presence of stereotyped behavior
This suggests a diagnosis of Autism Spectrum Disorder (DSM-5)
Regression after age 3 is very rare in autism, although loss of skills can occur between ages 12 and 24 months
The prognosis for such cases of regression is worse compared to early onset autism
Parents' reports of a psychosocial event (e.g., sibling birth) may be chance associations reflecting common life changes in preschool children.

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER

1.7 Attention-Deficit/Hyperactivity Disorder

Attention-Deficit/Hyperactivity Disorder (ADHD)

Definition:

Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development
Diagnosis requires onset before age 12, symptoms present for at least 6 months in multiple settings, and significant impairment to social, academic, or occupational functioning

Symptoms: *Inattention:

Not paying attention to details
Careless mistakes
Difficulty sustaining attention
Avoiding tasks requiring mental effort
Easily distracted
Forgetfulness *Hyperactivity-Impulsivity:
Fidgeting
Leaving seat when expected to remain seated
Running about or climbing inappropriately
Difficulty playing quietly
Talking excessively
Impulsive answers
Difficulty waiting turn
Interrupting others

Specifiers:

Predominantly Inattentive Presentation: multiple signs of inattention, few hyperactivity symptoms
Predominantly Hyperactive/Impulsive Presentation: many signs of hyperactivity or impulsivity, few inattention symptoms
Combined Presentation: many symptoms of both inattention and hyperactivity
In Partial Remission: some improvement but functional impairment persists

Diagnosis Considerations:

Rule out other conditions with similar symptoms (e.g., Schizophrenia, Bipolar Disorders, Depression, Anxiety Disorders, Substance Abuse, Personality Disorders)

Prevalence:

Approximately 5% of children and 2.5% of adults affected
More common in males than females
Most often diagnosed during elementary school years
Persists into early adolescence; hyperactivity may improve but inattention and impulsivity often persist

Impact:

Affects academic achievement, social relationships, occupational potential
Increases risk for substance use problems, antisocial behavior, and incarceration
Traffic accidents and injuries common.

Daydreamer

Pavel's Case Study

Background:

11 years old, brought for psychiatric consultation by parents
Described as:
- Socially immature
- Difficulty making friends
- Unhappy/unfocused
- Lazy
Current school year was particularly hard
Parents report:
- Pavel gets picked on, says the wrong things
- Demanding baby, never sleeps, cries a lot
- Quiet toddler
- B average in elementary school, grades dropped in 7th grade
- Absent-minded behavior, daydreams instead of focusing on homework
- Difficulty following instructions during basketball team
- Disorganized at school, trouble keeping attention on work
- Trouble understanding complex conversations
- Preferentially spends time on sports activities
- Has never developed a social network at camp
Parents have "excellent" marriage, only conflict over Pavel
Two younger brothers with no emotional problems

Psychiatric Evaluation:

Coerced by mother to attend evaluation
Admits trouble making friends, poor school performance
Favorite subjects: math and English, does poorly in both
Fights with father, criticisms can make him cry
Afraid of being labeled "crazy"
No problem sleeping, excellent appetite
Spends hours watching TV, prefers tennis over team sports
Wishes to become a professional basketball player
Consistently reported poor organizational skills
No disciplinary problems at school

Diagnosis and Treatment:

Diagnosed with Attention Deficit Hyperactivity Disorder (ADHD), predominantly inattentive presentation
Began taking methylphenidate, a stimulant, 2 months after evaluation
Improved academic performance, social skills, and relationships with parents

Into Everything

Evan's Behavior Characteristics:

Referred to a child psychiatrist due to difficulties at school
Suspended twice for disruptive behavior
Restless and unable to concentrate, roams around class
Fidgets with hands and feet, drops things on the floor
Difficult to manage in class: impulsive, lacks patience
Previous treatment with stimulants (amphetamine/dextromethamphetamine)

Symptoms of Attention Deficit Hyperactivity Disorder (ADHD):

Inattention: difficulty sustaining attention, seems unaware of surroundings
Impulsivity: acts before thinking, unable to wait for turn
Hyperactivity: restlessness, fidgeting, difficulty remaining seated

Evan's Symptoms:

Primary symptoms of hyperactivity and impulsivity
Inattention also present but less dominant
Diagnosis requires symptoms in multiple situations (school and home)
Onset before age 12: Evan's symptoms started at 3 years old
Predominantly Hyperactive/Impulsive Presentation.

A Wandering Mind

Patient Profile: Noreen Hamilton

Background:

Applied for treatment at a mental health clinic
Complained of wandering mind, difficulty focusing, easily distracted
Disorganized, restless, irritable, bad-tempered
Overreacts emotionally, often depressed
Relationship with long-time lover strained
Frequent arguments due to temper and inability to solve problems
Difficulty handling two young boys, described as "hyperactive"

Childhood History:

Placed in 95th percentile for childhood "hyperactivity"
Disciplinary problem in elementary school
Dropped out of high school
No treatment as a child
Saw counselor twice: once at age 20 and again at age 23
Marriage ended after birth of third child, briefly went to counseling
Received antidepressant medication without improvement

Diagnosis:

ADHD in Partial Remission (DSM-5, p. 59)
Long-term problems with mood lability, interpersonal relationships, difficulty controlling anger
No other characteristic features of Borderline Personality Disorder: identity issues, intense relationships, suicidal behavior, emptiness.

Symptoms:

Difficulty sustaining attention
Trouble organizing tasks
Easily distracted
As a child: failing to attend to details, problems following through on instructions.

Additional Information:

Ms. Hamilton's memory of childhood was sketchy
Her energy level was not unusually high.

SPECIFIC LEARNING DISORDER

1.8 Specific Learning Disorder

Specific Learning Disorder (SLD)

Definition: Difficulties learning and using academic skills despite interventions, affecting reading, writing, math, or other areas (DSM-5).

Types of SLD:

With Impairment in Reading: problems with word recognition, decoding, spelling, reading fluency, or comprehension. Dyslexia may be present.
With Impairment in Written Expression: difficulties in spelling accuracy, grammar, punctuation, organization.
With Impairment in Mathematics: issues with number sense, arithmetic facts, calculation, mathematical reasoning. Dyscalculia may be present.

Symptoms:

Manifest during school age when academic demands exceed abilities
Below expected levels for age on diagnostic tests
Severe enough to impact daily life negatively
Not explained by intellectual disabilities, sensory issues, mental disorders, or inadequate instruction.

Prevalence: 5% to 15% in children worldwide; 4% in adults.

Case Studies:

Janet's Case:

Struggling with learning and memory problems
Failing or barely passing some subjects (reading, English, arithmetic, spelling)
Average intelligence
No diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Conduct Disorder, or Intellectual Disability based on history and testing results.
Possible Specific Learning Disorder with Impairment in Reading.

Ed's Case:

Failing in school across multiple subjects: arithmetic, spelling, science
Average to high average intelligence
No diagnosis of ADHD, ODD, Conduct Disorder, or Intellectual Disability based on history and testing results.
Possible Specific Learning Disorder with Impairment in Mathematics.

MOTOR DISORDERS.

1.9 Developmental Coordination Disorder

Developmental Coordination Disorder (DCD)

Characteristics:

Acquisition and execution of coordinated motor skills below expected level for age
Manifestations include clumsiness, slow or inaccurate performance of motor skills
Affects daily living activities and academic/occupational functioning
Not the result of visual problems or neurological conditions

Prevalence:

5%-6% in children ages 5-11 years
More common in boys than girls

Onset:

Early childhood onset
Relatively stable course with persistence into adolescence for most children

Case Study: Juan

Background:

Late motor milestones (standing, sitting, walking)
History of bruises and falls
Difficulty with fine motor coordination (buttoning clothes, tying shoelaces, handwriting)
Avoidance of physical activities and team sports
Stomachaches as a way to avoid challenges
Above-average intelligence and academic performance, but below average on motor skills assessment

Manifestations:

Clumsiness: dropping things, bumping into objects
Slow or inaccurate performance: unable to catch ball, ride bike, complete puzzles, use utensils, write
Irritability and avoidance behavior due to motor difficulties

Diagnostic Criteria:

Substantially below expected level for age in motor skill acquisition and execution
Severe enough to impact daily living activities and academic/occupational functioning
Not the result of visual problems or neurological conditions.

1.10 Stereotypic Movement Disorder

Stereotypic Movement Disorder

Characteristics:

Repetitive, seemingly driven, and purposeless motor behavior (DSM-5, p. 77)
Hand shaking or waving, body rocking, head banging, self-biting, self-hitting
Maladaptive behaviors interfering with social and academic functioning
May result in self-injury and medical emergencies
Specifiers: With Self-Injurious Behavior, Associated With a Known Medical or Genetic Condition, Neurodevelopmental Disorder, or Environmental Factor

Prevalence:

Up to 3%—4% of the population (complex stereotypic movements)
Up to 16% of individuals with Intellectual Disability

Onset and Course:

Repetitive behaviors typically begin within first 3 years of life
Most children outgrow or improve with intervention
Persists more in individuals with Intellectual Disability

Case Study: "The Pretzel"

14-year-old boy with Severe Intellectual Disability and Blindness
Premature birth, retinopathy of prematurity, and cerebral dysfunction diagnosis
Self-injurious behaviors since early life, difficult to manage at home
Transferred to a new residential school for children with multiple disabilities
Stereotypic self-injurious and self-restraining behaviors interfered with daily activities and education
Focus of behavior modification program and antipsychotic medication treatment
Improvement when engaging in tasks with trusted teacher, regression upon departure
Lack of communicative language prevented assessment for Obsessive-Compulsive Disorder or Autism Spectrum Disorder diagnosis
Diagnosis: Stereotypic Movement Disorder With Self-Injurious Behavior (DSM-5, p. 77)

TIC DISORDERS

1.11 Tic Disorders

Tic Disorders

Definition:

A tic is a sudden, rapid, recurrent nonrhythmic motor movement or vocalization (DSM-5, p. 81)
Can be either simple or complex

Types of Tics:

Simple Motor Tics: Short duration, include eye blinking, shoulder shrugging, extension of extremities (DSM-5, p. 82)
Complex Motor Tics: Longer duration, can include a combination of simple tics, appear purposeful or imitate others' movements (DSM-5, p. 82)
Simple Vocal Tics: Throat clearing, sniffing, grunting (DSM-5, p. 82)
Complex Vocal Tics: Repeating one's own sounds or words, repeating last heard word/phrase, uttering socially unacceptable words (DSM-5, p. 82)

Tic Disorders in DSM-5:

Tourette’s Disorder: Multiple motor and one or more vocal tics, persistent for over 1 year, not caused by substances or medical conditions (DSM-5, p. 83)
Persistent (Chronic) Motor or Vocal Tic Disorder: Exclusively motor or vocal tics, persisting for over 1 year, no history of Tourette’s Disorder (DSM-5, p. 83)
Provisional Tic Disorder: Single or multiple motor and/or vocal tics, persisting less than 1 year (DSM-5, p. 84)

Prevalence and Characteristics of Tourette’s Disorder:

Rare disorder, prevalence in school-age children estimated at 0.3%-0.8% (DSM-5, p. 81)
More common in males than females
Onset typically between ages 4 and 6 years
Symptoms most severe around age 10 or 12
Often improves during adolescence but can persist into adulthood

Case Study: Embarrassed Sal Borelli

Diagnosis: Tourette’s Disorder (DSM-5, p. 83)
Onset at age 13, multiple motor and vocal tics
Functioned well academically despite tics
Military service led to temporary improvement but symptoms returned after discharge
Social life increasingly constricted due to tics
Treated with antipsychotic medication (pimozide), which eliminated 99% of symptoms

Case Study: Alan

Diagnosis: Tourette’s Disorder (DSM-5, p. 83)
Complex motor and vocal tics, onset at age 10
Obsessions and compulsions also present but not impairing enough to warrant additional diagnosis of Obsessive-Compulsive Disorder
Difficulty distinguishing complex motor tics from compulsions.

CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Overview:

Diagnostic class in DSM-5 that includes a range of disorders characterized by impaired thinking, behavior, and emotions indicative of loss of contact with reality
Psychosis: broadly defined term for impaired functioning in one or more domains

Domains of Symptoms:

Hallucinations: false sensory perceptions in the absence of external stimuli
- Auditory, visual, olfactory, gustatory, tactile, somatic hallucinations
- Distinguished from illusions, dreams, and imagery
Delusions: fixed, falsely held beliefs despite contradictory evidence
- Belief in supernatural or subcultural tenets not considered delusional
- Only when belief deviates markedly from framework is it considered delusional
Disorganized thinking or speech
- Fragmented, loosely associated thoughts and statements
- Difficulty maintaining train of thought
- Use of neologisms, perseveration, clanging
Grossly disorganized or abnormal motor behavior (including catatonia)
- Extremely abnormal behaviors not goal-directed
- Catatonic behaviors: dramatic decrease or increase in activity, decreased awareness of environment
Negative symptoms: deficits in normal mental functioning that impair functioning
- Diminished emotional expression (flattened affect)
- Avolition: lack of motivation to initiate and perform activities
- Diminished ability to experience pleasure, diminished speech output

Disorders in this Chapter:

Schizophrenia: persistent psychotic disorder with various types of symptoms and functional decline
Schizophreniform Disorder: briefer psychotic disorder that often progresses to Schizophrenia
Schizoaffective Disorder: persistent psychotic disorder with mixture of psychotic and mood symptoms
Delusional Disorder: persistent delusions without other psychotic symptoms
Brief Psychotic Disorder: psychotic symptoms resolving within 1 month
Catatonia: syndrome of catatonic symptoms
Substance / Medication-Induced Psychotic Disorder: hallucinations or delusions due to substance or medication use
Other Specified Schizophrenia Spectrum and Other Psychotic Disorders: psychotic presentations not meeting criteria for specific disorders
Psychotic Disorder Due to Another Medical Condition: hallucinations or delusions due to direct effects on the central nervous system
Schizotypal Personality Disorder: genetically related to Schizophrenia, discussed in DSM-5's Personality Disorders chapter.

Characteristic Features of Schizophrenia Spectrum and Other Psychotic Disorders

Disorder:

Schizophrenia
- Key characteristics:
  - Active-phase symptoms (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms) lasting at least 1 month
  - Duration of symptoms: 6 months or more
  - Level of functioning significantly impaired in major life areas
Schizophreniform Disorder
- Key characteristics:
  - Active-phase symptoms similar to Schizophrenia
  - Duration of symptoms: less than 6 months
  - Some degree of impairment, but not severe enough to interfere with major life areas
Schizoaffective Disorder
- Key characteristics:
  - Active-phase symptoms of Schizophrenia and Affective Disorder (e.g., Major Depressive Disorder or Bipolar Disorder)
  - Duration of symptoms: 6 months or more
  - Degree of impairment varies depending on the dominant symptom type
Delusional Disorder
- Key characteristics:
  - Persistent delusions without other psychotic symptoms
  - Duration: longer than 1 month
Brief Psychotic Disorder
- Key characteristics:
  - Active-phase symptoms of Schizophrenia or another psychotic disorder
  - Duration less than 6 months
  - Less severe than Schizophrenia
Catatonia
- Key characteristics:
  - Psychomotor disturbance with varying motor activity and engagement levels
  - May be associated with other psychiatric or medical conditions
Substance/Medication-Induced Psychotic Disorder
- Key characteristics:
  - Active-phase symptoms of psychosis (delusions, hallucinations) due to substance or medication use
  - Duration depends on the length of substance use
Other Specified Schizophrenia Spectrum and Other Psychotic Disorders
- Key characteristics:
  - Symptoms characteristic of a psychotic disorder
  - Do not meet full criteria for any specific psychotic disorder in this chapter
  - Cause clinically significant distress or impairment.

2.1 Schizophrenia

Schizophrenia

Definition:

Severe and debilitating mental disorder in DSM-5's Schizophrenia Spectrum and Other Psychotic Disorders
Characterized by cognitive, behavioral, emotional dysfunctions
Impairments in perception, inferential thinking, fluency and productivity of thought and speech, behavioral monitoring, cognition, emotional expression
Persists for at least 6 months with a significant impact on psychosocial functioning

Symptoms: Positive symptoms:

Delusions: distortion or exaggeration of inferential thinking
Hallucinations: distortions in perception
Disorganized speech: distortions in language, communication, and thought processes
Grossly disorganized or catatonic behavior: distortions in behavioral monitoring

Negative symptoms:

Avolition: restrictions in initiating goal-directed behavior
Diminished emotional expression: restrictions on range and intensity of emotions

Diagnosis:

At least two significant symptoms present for a significant amount of time during the same 1-month period, including at least one delusion, hallucination, or disorganized speech
Heterogeneous presentation with persistence and negative impact on psychosocial functioning
Differentiate from drug use or medical conditions

Additional Information:

Prodromal phase: a forerunner to the first active phase of the illness
Residual phases: milder versions of positive and negative symptoms between active phases
Cognitive impairment common, linked to academic and occupational impairment
- Problems with attention, memory, planning, organization, insight
Onset typically in late teens to early 30s (earlier for males than females)
Affects between 0.3% and 0.7% of the population.

Under Surveillance

Mr. Stanton's Case History:

Background:

44-year-old single, unemployed white man
Bringing him to the emergency room by police for striking an elderly woman
Gradual onset of delusions since law school:
- Convinced classmates were making fun of him
- Belief that girlfriend had been replaced
- Increasingly suspicious and withdrawn at work
- First reported hearing voices, leading to hospitalizations

Hospitalization History:

12 hospital stays, longest for 8 months
Last 5 years: only 1 hospitalization for 3 weeks
Regular antipsychotic medication use but often discontinued
Total social isolation, except for meetings with uncle and mental health workers
Manages own finances, cooks, cleans, reads Wall Street Journal

Delusions:

Belief that his apartment is center of large communication system
- Secret cameras monitoring activities
- Announcer comments on minor actions
- Neighbors and "actors" under surveillance
Two machines controlling experiences:
- Harassing voices from neighbor's machine
- Erotic dreams from "dream machine" (generates erotic dreams with black women)
Unusual experiences, such as altered shoes
Belief that great effort and resources are invested in keeping him under surveillance

Diagnosis:

Schizophrenia based on delusions, hallucinations, impairment in functioning, absence of mood disturbance or medical condition

Violence:

Assaulted elderly neighbor due to belief she operated machine causing voices
Possible diminished capacity for rational decision making and control if charged with a crime.

Additional Information:

Schizophrenia is the diagnosis based on DSM-5 criteria: delusions, hallucinations, severe impairment in functioning, absence of sustained mood disturbance or other medical condition or substance that can account for the symptoms.
Individuals with Schizophrenia are more likely to be violent than general population but account for less than 5% of societal violence.

Eating Wires

Mr. Rodriguez's Case Profile

Background:

40-year-old man, appears younger
12th hospitalization
Dressed in ragged overcoat, slippers, baseball cap
Wears several medals around neck
Affect ranges from anger to seductive behavior
Speech childlike, mincing step, exaggerated hip movements

Mother's Report:

Stopped taking medication a month ago
Hears voices, acts bizarrely
Previous hospitalizations for disorganized behavior
No known history of drug or alcohol abuse

Symptoms:

Disorganized behavior: inappropriate attire, missing medications
Incoherent speech with frequent clang associations: "eating wires and fighting fires"
Auditory hallucinations: hearing voices

Diagnosis: Schizophrenia (DSM-5, p. 99)

Dominated by disorganized behavior
Repeatedly discontinues antipsychotic medications

Challenges:

Lack of insight into mental illness and need for medication
Side effects of medication not preferred
Chronic disorganization interfering with adherence.

Low Life Level

Case Study: Louise Larkin

Background:

Pale, stooped woman of 39 years
Referred for psychiatric evaluation due to low functioning level
Previously a supervisor in occupational therapy department
Engaged to be married but broke off engagement, became disorganized and withdrawn

History:

12 years ago: Fired from job, wandered aimlessly, wore mismatched clothing
Hospitalized for 3 months with no available information
After hospitalization, became increasingly withdrawn and less functional
Spent most of time watching TV and cooking
Cooked bizarre combinations of ingredients, ate alone
Collected cookbooks and recipes, cluttered room
Stopped bathing, brushing hair or teeth
Lost 20 pounds, slept at odd hours
Became enuretic, wet bed frequently

Presentation on Admission:

Saturated affect, avoided looking at doctor
Denied depressed mood, delusions, or hallucinations
Answers became increasingly idiosyncratic and irrelevant
Replied that there's more of a take-off mechanism when younger about her strange cooking habits
Believed some writers were directing comical elements in an elemental way
Spoke with tangential speech, preoccupied with irrelevant details
Treated with antipsychotic and antidepressant medications

Progress:

Improved significantly during hospitalization
Returned home, enrolled in day program, continued outpatient treatment
Dropped out of cooking group due to preoccupation with irrelevant details
Demonstrated slight tangentiality in speech
Attends less demanding day program, takes good care of personal appearance.

Diagnosis:

Schizophrenia (DSM-5, p. 99)
Onset of symptoms in late 20s
Severe negative symptoms: lack of motivation, self-care difficulties, incoherent speech, disorganized behavior.

The Witch

Mrs. Dubois' Case

Background:

Admitted to hospital due to anxiety, suspicion, and hearing voices for 2 months
Husband reported normal behavior until 2 months ago
Withdrawn, neglected household duties, spent days wandering in her house
Felt frightened and feared something was going on
Heard voices day and night, preventing sleep
Believed neighbors were involved but no reason given
Discussed symptoms coherently without losing thread of thoughts

Symptoms:

Hearing voices: running commentary, identifying her as a witch, suggesting destruction
Somatic hallucinations: electrical discharges in genital area
Delusions: neighbors spying, thoughts not her own
No evidence of physical illness or substance abuse

Diagnosis:

Schizophrenia (DSM-5, p. 99)
Persistent psychotic symptoms interfering with functioning
Symptoms include hallucinations, delusions, disorganized speech and behavior, negative symptoms
Onset at age 45 is relatively unusual but appropriate diagnosis due to duration of symptoms (14 months)

History:

No major depression prior to hospitalization
Some depression after admission but time-limited
Previously regarded as humbug: telepathy, clairvoyance
Discontinued medication with reappearance of voices

Unusual Aspects:

Age at onset (45 years old)
Good social functioning before symptom onset
Paranoid delusions and hallucinations as opposed to disorganized speech and behavior, negative symptoms
Visual, somatic, and olfactory hallucinations present.

Star Wars

Susan Ashcroft's Case Study

Background:

Age: 15 years old
Request for placement advice from school district authorities
Difficulty in school, behavioral issues at home
Diagnosed with emotional disturbance

Behavioral Patterns:

Disruptive in class with animal noises and fantasies
Aggressive towards parents and brother
Obsession with Star Wars, space, and futuristic inventions
Unpredictable behavior, strange stories, talking to herself
Sleep disturbances and wandering at night
Preoccupation with making robots and complex calculations
Claims of hearing voices and communicating with a creature
Delusions and hallucinations

Medical History:

Prenatal and perinatal unremarkable
Developmental milestones delayed, IQ in the low 70s
Concerns about intellectual ability since school entry
Previous evaluations suggested bizarre thought processes and fragmented ego structure
No suicide attempts or suicidal ideation reported

Family History:

Parents in their early 40s, taciturn father, loquacious mother
Mother claims unusual childhood experiences in India with dramatic episodes
Restricted relationship between parents
Older brother, apparently normal child with average school career
Brother avoids spending time with Susan due to her behavior

Assessment:

Schizophrenia diagnosis based on delusions and hallucinations
Possible Autism Spectrum Disorder consideration: severe difficulties in social interaction, restricted behaviors, preoccupation with space
Mother's unusual beliefs and history suggestive of Schizotypical Personality Disorder.

2.2 Schizophreniform Disorder

Schizophreniform Disorder

Diagnostic Features:

Shares most diagnostic features with Schizophrenia but duration is between 1 and 6 months
No requirement for markedly below functioning level before symptom onset

Clinical Situations:

For individuals who have recovered after a psychotic episode lasting 1-6 months
For individuals in the midst of a psychotic episode that has lasted less than 6 months

Prognosis:

Individuals with Schizophreniform Disorder have better long-term prognosis than Schizophrenia
Factors associated with good prognosis:
- Onset of full-blown psychotic symptoms within 1 month of behavior change
- Confusion or perplexity at the height of psychotic episode
- Good functioning before onset of psychosis

Case Study: Late Bloomer (Jeanette Fielding)

35-year-old single, college-educated black woman
Escorted to emergency room after sister's concern about erratic work patterns
Only prior psychiatric contact was brief therapy in college
Experienced bizarre symptoms, including "thought broadcasting"
Poised and relaxed appearance, despite symptoms
Attributed job loss to economy, denied mood disturbance or psychotic symptoms
Believed people could read her thoughts and repeat them, felt overwhelmed by this ability
Considered hiring a hit man to threaten or eliminate upstairs neighbors
Discharged from hospital after 2 weeks, stopped attending clinic follow-up
Treated with antipsychotic medication, which remitted symptoms within months
Obtained work with temporary employment agency

Postpartum Piety

Case Study: Mrs. Zela Akerele's Postpartum Psychosis

Background:

30-year-old high school teacher from Lagos, Nigeria
Married with five children
Complicated delivery due to excessive bleeding and infection
Hospitalized for 3 weeks postpartum

Symptoms:

Agitated behavior
Dazed appearance
Belief in being a sinner, needing reborn
Fasting and keeping vigil through the nights
Claiming to wrestle with spirits
Accusations against psychiatrist and doctors
Delusions of being filmed, attacked, or poisoned
Announcing riots in town
Belief that doctors are "idol worshipers"
Seeking help from priests and religion
Hallucinations with religious content
Delusions of guilt
Suicidal ideation (implied)

Diagnosis:

Postpartum psychosis or Schizophreniform Disorder
- DSM-5 does not offer a specific postpartum psychosis diagnosis
- Mrs. Akerele's symptoms do not fit neatly into Manic Episode, Major Depressive Episode, Brief Psychotic Disorder, or any other DSM-5 diagnostic category

Treatment:

Antipsychotic medication: chlorpromazine
Electroconvulsive therapy (ECT) - six treatments
Traditional healing and spiritual church healers in Nigeria

Prevalence and Considerations:

Postpartum psychosis prevalence is 0.1%-0.2% of the population
One of the rarer psychiatric disorders but considered a psychiatric emergency due to rapid onset and potential for severe outcomes
DSM-5 includes the specifier "With Peripartum Onset" that can be applied to various diagnoses if symptoms develop during pregnancy or within 4 weeks postpartum
ECT is an effective treatment for postpartum psychosis, although traditional healing methods are often preferred in Nigeria.

2.3 Schizoaffective Disorder

Schizoaffective Disorder

Definition:

Hybrid of Schizophrenia/Schizophreniform Disorder and Mood Disorder (Bipolar or Major Depressive)

Characteristics:

Overlapping psychotic and mood symptoms: delusions, hallucinations, mania, depression
Two types based on pattern of mood symptoms: Bipolar Type or Depressive Type

Differentiation from Other Disorders:

Schizophrenia: less time with mood symptoms present (minority of illness duration)
Psychotic Mood Disorders: psychotic symptoms occur only during mood episodes

Treatment and Prognosis:

Treatment: mood-stabilizing medications for Bipolar Type, antidepressants for Depressive Type, antipsychotics for psychotic symptoms
Long-term prognosis: better than Schizophrenia but worse than psychotic Mood Disorders

Case Study: Foster Mother Sophie Baumann

Background:

44-year-old mother of three teenagers, separated from husband for 10 years
Shy, emotional constricted person with no history of illness before last year
Previously cared for foster children full time for 4 years

Symptoms and Diagnosis:

One year ago: psychotic symptoms (delusions, auditory hallucinations) without mood disturbance
Hospitalized, received antipsychotic medication (ziprasidone), developed Major Depressive Episode
Treated with antidepressant (venlafaxine), persistent depression despite multiple trials of different medications
Diagnosis: Schizoaffective Disorder, Depressive Type (no evidence of mania)

2.4 Delusional Disorder

Delusional Disorder

Persistent psychotic disorder with primary symptom being one or more delusions lasting at least 1 month
Absence of other psychotic symptoms like hallucinations, disorganized thinking or behavior (Schizophrenia)
No obvious signs of mental illness apart from impact on functioning
Examples: belief in secret government surveillance, jealousy, erotomania, somatic sensations, grandiosity
DSM-5 provides various subtypes based on predominant theme of delusional belief: Persecutory, Jealous, Erotomanic, Somatic, Grandiose, Unspecified
Rare disorder with an estimated prevalence of 0.2%
Most common form is the Persecutory Type
No major gender differences in overall frequency
Can start from adolescence but typically begins in middle to late adulthood
Sudden onset
Long-term outcome varies, up to half of patients may experience lasting remission.

Contract on My Life

Patient Profile: Robert Polsen

Background:

45-year-old married black postal worker and father of two
Bringed to emergency room by wife due to delusion of a "contract out on his life"

Symptoms:

Belief that coworkers were avoiding him, later convinced they were part of "hit team"
Frightened by presence of large white cars in his neighborhood
Refused to leave apartment without an escort
Delusional belief that boss had put a contract out on his life

Diagnosis:

Delusional Disorder (DSM-5, p. 90)
Persecutory Type

Behavioral Observations:

Well-adjusted and outgoing person until delusion emerged
Anxious mood predominant throughout hospitalization
Denied hallucinations or other psychotic symptoms apart from delusion
Initially denied being depressed, but later reported difficulty sleeping

Treatment:

Received antipsychotic medication (risperidone) during first week of hospitalization
Beliefs did not fade significantly until continued treatment over 3 weeks
At discharge, believed "boss has called off the contract"

Delusional Thinking:

Diagnostically challenging to determine if belief is delusional or based in reality
In this case: boss's reaction to grievance hearing stretches credibility, indicating it is delusional
Typical referential nature of persecutory delusions present (misinterpreting innocuous actions as significant)
Incorporation of additional individuals into paranoid belief system

Atypical Aspects:

Reluctance to seek help is not typical for Persecutory Type Delusional Disorder
Effectiveness of antipsychotic medication in treatment is often less than Schizophrenia, Bipolar Disorder, or Major Depressive Disorder.

Dear Doctor

Mrs. Field's Case Study

Symptoms:

Belief that a physician is intensely in love with her, despite no declaration from him
Interpreting casual remarks and gestures as cues to his feelings
Felt the physician gave her significant glances and made suggestive movements
Believed the physician was married and couldn't admit his feelings
Experienced frequent, intense abdominal sensations (later identified as sexual feelings)
Became increasingly distressed and agitated, leading to inability to work

Psychiatric Evaluation:

Initially embarrassed to confide in male psychiatrist
Transferred to a female psychiatrist who helped her pour forth her story
Diagnosed with Delusional Disorder, Erotomanic Type (DSM-5, p. 90)
Unshakable belief that physician is passionately devoted to her
Responded well to medication (pimozide) over a period of 3-4 weeks
Remains well 3 years later, still believes physician loves her but is no longer distressed

Background:

Illegitimate child whose stepfather was excessively strict
Learned slowly and always in trouble at home and school
Grew up anxious and afraid, consulted many doctors for hypochondriacal concerns
Insecure in company
Asexual marriage with husband who was perceived as overly critical and demanding
Could not confide in her husband about the "love" affair

Erotomanic Delusion:

Convinced that another person, often more socially prominent, is secretly in love with them
Individuals may stalk celebrities due to this delusion
More common among women, but men can be affected as well
Can lead to aggression toward companions of the "love object"

Unfaithful Wife

Case Study: Unfaithful Wife

Patient Profile:

Marnie Callahan: 48-year-old woman who took an overdose of sleeping pills
Casey Callahan: 50-year-old husband with delusional beliefs about wife's infidelity

Background:

Marriage was stable until onset of husband's irrational jealous behavior
Mr. Callahan had a history of heavy drinking and occasional violence in his youth but had ceased these behaviors by mid-30s
He had never used street drugs

Symptoms:

Increasingly jealous and accusatory towards wife for past 18 months
Belief in irrational evidence: multiple lovers, late night rendezvous, communications via lights and mirrors
Wrong-number telephone calls seen as proof of infidelity
Refused to accept food or cigarettes from his wife
No physical assaults but became increasingly distressed and haggard, lost 15 pounds
Fearful wife may leave him, considering violence herself
Wife considered leaving him due to husband's irrational behavior

Diagnosis:

Delusional Disorder, Jealous Type (DSM-5)
Belief in his wife's infidelity: grossly improbable and extreme behavior indicators of delusion
Possible secondary persecutory delusion that she was trying to poison him

Treatment:

Anti-psychotic medication Pimozide
Effective in eliminating delusions but continued treatment needed for symptom management.

Fleas

Patient Case: Mr. Wallace's Flea Infestation

Background:

Consulted dermatologist due to fleas for a year, no evidence found
Referred for psychiatric consultation
Initially resisted recommendation
Had history of myocardial infarction (heart attack) and smoking cessation
Previous marriage ended in desertion, lived alone for many years

Symptoms:

Delusional belief in flea infestation
- Visual misinterpretations or hallucinations
- Unshakeable conviction
Anxiety and anger at times
Normal consciousness and cognitive functions

Psychiatric Assessment:

Primary symptom: somatic delusion
- Delusional Disorder diagnosis (DSM-5)
  - Exception for visual hallucinations related to delusional content
Initially sought help from non-psychiatric physicians
Reluctantly agreed to medication treatment (pimozide)
Improved after 6 months, stopped medication on his own

Additional Information:

Alert and friendly demeanor during interview
Angry when discussing dismissive doctors
Normal mood except for anxiety and anger
Stable basic personality.

2.5 Brief Psychotic Disorder

Brief Psychotic Disorder

Symptoms:

Symptoms of psychosis that last anywhere from a few days to 1 month
Positive symptoms: delusions, hallucinations, disorganized speech, or grossly disorganized behavior
Emotional turmoil or overwhelming confusion
Rapid shifts in mood states (agitation and irritability to depression)

Characteristics:

Abrupt onset, often following major life events causing significant emotional upset
Episodic nature, may not last long but can recur
Best prognosis among psychotic disorders for most individuals

Case Study: The Socialite Mrs. Cabot

Socialite experiencing a brief psychotic episode after friend's death and major life stressors
Convinced friend was not killed in car accident, part of a plot to deceive her
Believed to be under surveillance (phone tapped, rooms "bugged")
Heard high-pitched undulating sound, believed to be an ultrasound beam aimed at her
Diagnosis unclear; medical evaluation necessary to rule out drugs or other causes
Symptoms resolved within days and she returned to normal.

2.6 Catatonia Associated With Another Mental Disorder/Catatonic Disorder Due to Another Medical Condition

Characteristics of Catatonia:

Marked psychomotor disturbance
Decreased motor activity: stupor, catalepsy, waxy flexibility
Decreased engagement: mutism, negativism
Excessive and peculiar motor activity: complex behaviors, facial grimacing, echolalia, echopraxia
May require careful supervision to avoid self-harm or harming others

Association With Mental Disorders:

Commonly associated with severe depression or bipolar disorder
Occasionally due to schizophrenia or other psychotic disorders

Case Study: Mute Cathy

25-year-old mother with systemic lupus erythematosus (SLE)
Admitted in acute confusional state, uncontrollable agitation
Developed rigidity, mutism, unresponsiveness, facial grimacing
Alternated between catatonic negativism and stupor, and periods of catatonic excitement with agitation and psychotic symptoms
Diagnosis: Delirium Due to Systemic Lupus Erythematosus (DSM-5) and Catatonic Disorder Due to Systemic Lupus Erythematosus (DSM-5)

Treatment:

Haloperidol, lorazepam, methylprednisolone
Electroconvulsive therapy (ECT)
Absence of antineuronal antibodies in cerebrospinal fluid after treatment indicates positive response.

2.7 Substancel/Medication-Induced Psychotic Disorder

Substance/Medication-Induced Psychotic Disorder

Determining Cause of Psychotic Symptoms:

Important for diagnosis and treatment
Drug use may cause temporary or persistent psychotic symptoms

Drugs Known to Cause Psychotic Symptoms:

Alcohol: Intoxication or withdrawal
Amphetamines, cocaine, PCP, cannabis
Hallucinogens: LSD, psilocybin, mescaline
Inhalants: Glue, paint thinner
Sedative, hypnotic, or anxiolytic medications: Valium, Xanax, Ambien

Diagnosis:

Substance/Medication-Induced Psychotic Disorder (if psychotic symptoms occur only during use)
Delusional Disorder (if preexisting psychotic disorder is present and not related to drug use)
Schizophrenia (if primary psychotic disorder with no history of drug-induced psychosis)

Case Studies:

Agitated Businessman:

Paranoid delusions and hallucinations
History of Narcolepsy treated with methylphenidate
Increasing doses for better alertness
Diagnosis: Methylphenidate-Induced Psychotic Disorder, With Onset During Intoxication

Threatening Voices:

Auditory hallucinations and delusions
Daily alcohol use leading to gastrointestinal distress
Interrupted alcohol use causing psychotic symptoms
Diagnosis: Alcohol-Induced Psychotic Disorder, With Onset During Withdrawal

2.8 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

Ms. Galvez's Case

Background:

Attractive 25-year-old Dominican mother of two children
Redhead with a pouty and seductive demeanor
Referred to psychiatric emergency room for hearing voices telling her to kill herself
Refused to discuss marital problems or depression, but reported anxiety and insomnia

History:

First experienced auditory hallucinations 7 years ago after the birth of her first child
Tried nail polish remover in a suicide attempt but did not act on voices since then
Functioned well despite intermittent hallucinations: finished high school, raised children, and worked full time as a salesperson

Psychiatric Evaluation:

Angry and insistent during interview, alternating with flirtatious behavior
Refused to discuss depression or anhedonia, but reported increased tearfulness and rumination about "bad things"
Denied alcohol or drug use, but a toxicology screen was negative
Stopped taking antipsychotic medication before interview

Diagnosis:

No diagnosis based on DSM-5 Schizophrenia Spectrum and Other Psychotic Disorders applied
Considerable evidence of auditory hallucinations in the general population as a human variation
No delusions, disorganization of personality, or deterioration in functioning

Discussion:

Doctor concerned about voices telling Ms. Galvez to kill herself, but she does not consider them problematic
Functioning relatively well despite intermittent hallucinations
Some individuals and advocacy groups view auditory hallucinations as a human variation rather than a mental disorder.

Sex Problem

Case Study: Mrs. Janine Birnbaum's "Sex Problem"

Background:

43-year-old housewife seeking outpatient treatment for a self-reported "sex problem"
Husband, Joseph, provides history of her alleged extramarital affairs and memory loss
Patient agrees with husband's assessment but refuses to discuss experiences
Lack of interest in sexuality, compulsive drive despite lack of memories

Marital Dynamics:

Long-term marriage (over 20 years)
Dominant and jealous husband
Fearful wife of husband's rages
Husband suggests wife see psychiatrist for hypnosis

Diagnostic Considerations:

Dissociative Amnesia (DSM-5, p. 641)
Neurocognitive Disorder Due to Another Medical Condition (DSM-5, p. 641)
Substance Use Disorder

Uncovering the Truth:

Husband's delusional jealousy questioned
Wife may not have dissociative disorder but has adopted husband's delusion
Shared psychotic disorder or folie a deux (DSM-5, p. 122)

Characteristics of Shared Psychotic Disorder:

Transfer of delusions from one person to another in close relationship
Delusional individual is chronically ill and influential
Secondary individual is more suggestible, passive, or lacking self-esteem

Implications:

If the individual with shared delusion is separated from primary delusional individual, they may abandon the delusion.

CHAPTER 3 Bipolar and Related Disorders

Bipolar and Related Disorders

Characterized by mood instability with periods of abnormally high mood (Manic Episodes) and abnormally low mood (Major Depressive Episodes)
Manic Episodes:
- Persist for at least 1 week, significantly interfere with functioning
- Accompanied by increased activity or energy, euphoric or expansive mood, decreased need for sleep, racing thoughts, distraction, increased activity in multiple areas of life
- May include symptoms such as: inflated self-esteem, delusions, hallucinations, flight of ideas, motor restlessness, reckless behavior
- Differentiated from Hypomanic Episodes by severity and impact on functioning
Hypomanic Episodes:
- Minimum duration of 4 days, does not significantly negatively impact functioning
- Accompanied by increased activity or energy, euphoric or irritable mood, decreased need for sleep, racing thoughts, distraction, increased activity in multiple areas of life
Bipolar I Disorder: At least one Manic Episode that may have been preceded by or followed by Hypomanic or Major Depressive Episodes
Bipolar II Disorder: At least one Hypomanic Episode and one Major Depressive Episode, no Manic Episodes
Cyclothymic Disorder: Numerous periods with hypomanic symptoms that do not meet criteria for a Hypomanic Episode, numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode, present more days than not for at least 2 years
Substance/Medication-Induced Bipolar and Related Disorder: Prominent and persistent elevated, expansive, or irritable mood due to substance or medication
Bipolar and Related Disorder Due to Another Medical Condition: Prominent and persistent elevated, expansive, or irritable mood that is the direct physiological consequence of another medical condition (e.g., hyperthyroidism, traumatic brain injury).

3.1 Bipolar 1 Disorder

Bipolar I Disorder (BPD-1)

Characteristics:

Mood Disorder with Manic and Major Depressive Episodes
Single Manic Episode required for diagnosis, but multiple episodes common
Diagnosis often heralded by severe Manic Episode requiring hospitalization
Major Depressive Episodes similar to those in Major Depressive Disorder
Can begin with Major Depressive Disorder before first Manic Episode
Manic Episodes may be triggered by antidepressant medication or treatment methods like light therapy or ECT

Symptoms:

Manic Episode: hypersensitivity to stimuli, elated mood, inflated self-esteem, rapid speech, racing thoughts, decreased need for sleep
Major Depressive Episode: depressed mood, loss of interest or pleasure, changes in appetite or weight, sleeping too little or too much, psychomotor agitation or retardation, low energy and activity, feelings of guilt or worthlessness, difficulty concentrating, thoughts of suicide

Diagnostic Specifiers:

Type of episode driving current treatment: Manic, Hypomanic, or Major Depressive
Presence of delusions or hallucinations (With Psychotic Features)
Catatonia symptoms (With Catatonia)
Anxiety symptoms (With Anxious Distress)
Mixed features (With Mixed Features)
Melancholic features or atypical features (applies only to Major Depressive Episode)
Severity of episode: Mild, Moderate, Severe
Current condition: In Partial Remission or In Full Remission

Temporal Features:

Rapid Cycling: 4+ Manic, Hypomanic, or Major Depressive Episodes within a year
Peripartum Onset: episodes have onset during pregnancy or within 4 weeks of delivery
Seasonal Pattern: regular occurrence during the same time of the year

Prevalence:

Approximately 0.6% prevalence in the US
Equally common in men and women

Onset:

Mean age at onset: approximately 18 years, but can start during childhood or older ages.

Radar Messages

Alice Braverman's Case Study

Background:

Alice, a 24-year-old copy editor from Colorado, sought psychiatric help to continue her treatment with lithium carbonate for mood stabilization.
She described an uneventful period during her senior year in college when she experienced depression and mania episodes.

Depression Episode:

Felt depressed, had loss of appetite, difficulty sleeping, and racing thoughts
Believed there was a hole in her head through which "radar messages" were being sent to her
Heard voices ordering her to perform sexual acts or speaking about her in the third person
Friends took her to a hospital emergency department and she was admitted to a psychiatric unit

Manic Episode:

Experienced increased energy, decreased need for sleep, and pressured speech
Believed her thoughts were racing and that emotions beyond her control were being produced
Developed bizarre delusions of radar messages controlling her thoughts
Displayed symptoms of mania without grandiosity or invulnerability themes

Diagnosis:

Bipolar I Disorder, Current Episode Manic, Severe, With Mood-Incongruent Psychotic Features
Manic Episode without Major Depressive Episode
Considered a preventive measure, lithium carbonate was used to maintain full remission for the past 6 months.

Family History:

Father had a severe episode of depression with suicidal ideation
Paternal grandmother committed suicide during what appeared to be a depressive episode

Triple Divorcée

Ms. Sandra Kovacs' Case

Background:

37-year-old paralegal in a prestigious law firm
Thrice divorced
Hospitalized for suicide attempt due to depression
History of chronic mild depression since her 20s
Previously on citalopram, switched to desipramine

Medication Switch:

Desipramine: older tricyclic antidepressant
Reported feeling more energetic and confident at work
Decided to discontinue the medication without consulting her psychiatrist
Experienced increased energy, racing thoughts, rapid speech, poor judgment, euphoria, decreased need for sleep

Manic Episode:

Occurred after switching from citalopram to desipramine
Six out of seven symptoms: euphoria, increased energy and activity, increased self-esteem, decreased need for sleep, rapid speech, racing thoughts
Impaired judgment
Considered a Moderate manic episode (DSM-5)

Diagnosis:

Bipolar I Disorder, Current Episode Manic, Moderate (DSM-5)

Symptoms of Mania:

Euphoria or irritable mood
Increased energy and activity
Decreased need for sleep
Rapid speech
Racing thoughts
Impaired judgment
Distractibility (not present in Ms. Kovacs' case)

Roller Coaster

Rapid Cycling Bipolar I Disorder (Mr. Eaton's Case)

Background:

Ernest Eaton, 39 years old
Unemployed for several years due to mood disorders
Agreed to comprehensive psychiatric evaluation after wife's threat of leaving him

Mood Swings:

Alternating periods of elation and depression
No "normal" days
Energy and hyperactivity (euphoria)
- Overactivity
- Overtalkativeness
- Excessive involvement in pleasurable activities without consideration for consequences (overspending, sexual flings)
Depression
- Fatigue, lack of motivation
- Depressed mood
- Guilt about irresponsibility and excesses during manic periods
- Stopped eating, bathing, shaving
Denied substance use other than alcohol during manic episodes

Diagnosis:

Bipolar I Disorder, Current Episode Manic (DSM-5)
- Characteristic symptoms: decreased need for sleep, overactivity, overtalkativeness, excessive involvement in pleasurable activities without consideration for consequences
- Severity: Moderate
- Rapid cycling specifier applies due to more than four episodes within one year

Additional Information:

Previous job dismissal due to suspicion of drug use despite no evidence
Minimally cooperative and noncompliant with medications (lithium carbonate, sodium valproate, antidepressants) during psychiatric evaluation
Quickly found a new job and did well for following year but stopped taking medication and had another manic episode.

Differential Diagnosis:

Rapid cycling is common in women and often mistaken for drug abuse
Mr. Eaton's unusual behavior was attributed to drug use by his employers

Treatment:

Anticonvulsant medications, such as sodium valproate, effective for rapid cycling Bipolar Disorder.

Wealthy Widow

Case Study: Wealthy Widow

Background:

Mrs. Anne Kettering, 72-year-old widow
Referred for psychiatric evaluation against her will by sons
Announced engagement to a 25-year-old male nurse
Active social life resumed after husband's death
Concerns from family due to frequenting bars and spending large sums of money

Initial Presentation:

Extremely angry at sons and psychiatrist
Insists on doing things for herself for the first time in her life
Accuses sons of trying to commit her for their gain
Overtalkative, refusing interruptions
Describes fiancé's physical attributes and sexual abilities
Enjoys nightlife and after-hours activities with fiancé
No memory impairment or obvious orientation issues

Symptoms:

Alternating irritable and expansive mood
Pressured speech
Decreased need for sleep
Poor judgment (signing house over to new lover)

Diagnosis:

Bipolar I Disorder, Current Episode Manic, Moderate

Considerations:

Rule out underlying medical conditions causing bipolar disorder
Provisional diagnosis until medical workup is complete.

Praying Athlete

Dion Robinson's Case History

Background:

24-year-old black man named Dion
Mute and rigid, resisting attempts to be moved
Friends brought him to emergency room after playing basketball
Previously hospitalized a year before with similar symptoms

Symptoms:

Catatonia:
- Sudden bizarre behavior: becoming mute and rigid
- Rigid posturing, frozen position
- Waxy flexibility: arms can be manipulated and held
Manic Episode:
- Expansive mood, hyperactivity
- Delusionally grandiose: communicating directly with God
- Psychomotor agitation: pacing around the unit
- Stopped sleeping at night
- Hypersexual: sexually demanding
Depressive Episode:
- Extremely depressed, socially withdrawn
- Spent up to 14 hours a day sleeping
Diagnosis:
- Bipolar I Disorder, Current Episode Manic, With Mood-Congruent Psychotic Features, With Catatonia (DSM-5, p. 123)
Previous Hospitalization:
- Admitted a year before with atypical psychosis
- Left against medical advice
Treatment:
- Antipsychotic medication: risperidone
- Mood-stabilizing medication: lithium carbonate
Outcome:
- Normal mental status 12 days after admission
- Mild depression 1 month post-discharge, managed with increased lithium dose
Follow-up:
- No further psychotic or depressive symptoms during the year of follow-up.

You May Keep the Yacht

Case Study: Eddie Stover

Background:

Escorted from jail to forensic psychiatry unit due to "gravely disabled because of a psychiatric disorder"
In jail uniform, refused food and medication, stayed naked under blankets
History of intravenous heroin use, syphilis infection treated 8 years prior, gunshot wound to the heart
Refused physical examination and some tests (except urinalysis and VDRL test)

Psychiatric Examination:

Tall, thin, black male with unruly hair and intense affect
Rambling, loud, pressured speech with guarded and questionably reliable responses
Bizarre responses in spelling "world" as "w-zero-r-l-d"
Denied hallucinations, violent impulses, or previous psychiatric treatment
Most likely diagnosis: Schizophrenia or drug intoxication
Prescribed antipsychotic medication but refused

Hospitalization:

Released from criminal custody when rape charges were dropped
Cooperative but agitated and unable to sleep on locked ward
Complained of homosexual activity by "others" despite no roommates
Placed in seclusion due to fear of losing control, later calmed with door locked
Displayed bizarre, ritualistic movements and increasing withdrawal
Refused medication and solid food but drank fluids
Playful and aloof attitude
Continued to behave inappropriately during court-ordered treatment hearing
Lost hearing due to lack of rational ability to refuse medication
Discharged from involuntary treatment when rape charge dropped
Indicated plans to purchase "superior leather goods" and return to Midwest

Discussion:

Cultural differences may lead to misdiagnosis: Mr. Stover's popular Caribbean hairstyle perceived as "unruly" instead of flamboyant
Possible diagnosis of Bipolar I Disorder, With Mood-Incongruent Psychotic Features instead of Schizophrenia or substance intoxication.

3.2 Bipolar II Disorder

Bipolar II Disorder

Characteristics:

Clinical course: one or more Hypomanic Episodes, one or more Major Depressive Episodes, no lifetime Manic Episodes
Individuals may initially present as recurrent Major Depressive Disorder
Important to inquire about possible presence of Hypomanic Episodes during nondepressed periods

Hypomanic Episodes:

Must have abnormally elevated or irritable mood
Cannot have psychotic features (unlike Manic Episodes)
Can be overlooked if not specifically inquired about
May lead to overdiagnosis of Bipolar II Disorder in individuals with frequent periods of depressed mood

Comparison to Bipolar I Disorder:

Slightly more common than Bipolar I Disorder (0.8% vs. 0.6%)
No gender difference in prevalence
Average age at onset slightly later, mid-20s
Initially presents with Major Depressive Episodes

Case Study: "Ellen Waters"

Part-time graduate student living alone, supported by home health aide work
Psychotherapist referred for medication consultation due to continued depressed mood and panic attacks
Chronic depression since childhood, with occasional elevated mood and increased energy episodes
Hypomanic Episodes indicated by abnormally elevated mood, decreased sleep, increased activity, racing thoughts
Currently experiencing Major Depressive Episode with atypical features (reverse vegetative symptoms)

Additional Specifiers:

With Atypical Features: refers to the presence of reverse vegetative symptoms in Major Depressive Episodes.

3.3 Cyclothymic Disorder

Cyclothymic Disorder

Characteristics:

Chronic fluctuating mood disturbance
Mildly elevated and mildly depressed periods present for most of the time
Periods of normal mood between episodes not required
Diagnosis based on symptoms present for at least 2 years
Can cause significant problems, but usually less impairing than Bipolar I or II Disorder
Onset usually in adolescence or early adulthood
Prevalence approximately 0.4%-1% in general population, more in mood disorder clinics (3%-5%)

Case Study: Car Salesman Geoffrey Fisher

Alternating cycles of "good times and bad times" since age 14
"Bad periods": last 4-7 days, characterized by oversleeping, lack of energy, confidence, and motivation
"Good periods": overconfidence, increased activity, poor judgment (e.g., promiscuity)
Irritable outbursts during good periods can precede transition back to bad days
Use of marijuana to help adjust to daily routines
Uneven performance at work, arguementative with customers and loses sales
Diagnosis: Cyclothymic Disorder

3.4 Substance/Medication-Induced Bipolar and Related Disorder

Substance/Medication-Induced Bipolar and Related Disorder

Symptoms of Manic, Hypomanic, and Major Depressive Episodes:

Caused by:
- Intoxication with certain substances (alcohol, phencyclidine, hallucinogens, sedatives/hypnotics/anxiolytics, amphetamines or cocaine)
- Withdrawal from certain substances (alcohol, sedatives/hypnotics/anxiolytics, amphetamines or cocaine)
- Side effects of certain medications (corticosteroids, androgens, levodopa)
Diagnosis: Substance/Medication-Induced Bipolar and Related Disorder

Case Study: Sleepless Housewife

Ms. Einbach: 28-year-old mother of two from Germany with no prior psychiatric history
Developed mood changes after taking new oral antibiotic, ofloxacin
- Insomnia, elevated mood, racing thoughts, increased activity
- Stopping the drug led to depressive symptoms (dysphoria, loss of energy, lack of appetite, loss of interest)
- Intermittent manic and depressive symptoms
Also experienced panic attacks

Diagnosis:

Ofloxacin-Induced Bipolar and Related Disorder
Ofloxacin-Induced Anxiety Disorder with Panic Attacks (optional)
Paranoid ideation also likely a reaction to the ofloxacin

CHAPTER 4 Depressive Disorders

Depressive Disorders

Characteristics:

Among most common and disabling mental disorders worldwide
Classified separately from Bipolar and Related Disorders in DSM-5
All characterized by sad, empty, or irritable mood with somatic and cognitive changes impacting function
Differ in accompanying clinical features, onset/course, duration, severity, and presumed etiology

Types of Depressive Disorders:

Disruptive Mood Dysregulation Disorder: Persistent irritability and dyscontrol episodes
Major Depressive Disorder: Changes in mood, cognition, sleep/eating patterns for 2+ weeks
Persistent Depressive Disorder (Dysthymia): Chronic depression for 2+ years (1 year children)
Premenstrual Dysphoric Disorder: Depression symptoms before menses, remitting after
Depressive Syndromes: Caused by substances/medications or medical conditions

Relationship to Other Disorders:

Part of "internalizing" spectrum, related to negative affectivity personality trait
Distress vs. anxiety characterizes different disorders within the spectrum

4.1 Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD)

New disorder in DSM-5 for children diagnosed with severe recurrent temper outbursts
Symptoms:
- Verbal yelling and screaming
- Behavioral physical aggression toward people or property
- Outbursts grossly disproportionate to situation/provocation
- Occur frequently (3+ times weekly)
- Persistently irritable or angry mood most of the time
Diagnostic criteria:
- Temper outbursts and irritable/angry mood present in at least two settings
- Severe symptoms in at least one setting
- Duration of at least 1 year, no periods of 3 months or more without symptoms
- Onset before age 10, restricted to ages 6-18
- No Manic/Hypomanic Episodes (DSM-5, p. 124)

Characteristics and Statistics:

Common mental disorder in pediatric mental health settings
More common among boys than girls
Persistent, lasting at least 1 year (50% longer)
Increases risk of Major Depressive Disorder or Anxiety Disorders in adulthood
Often includes other childhood disorders: Oppositional Defiant Disorder, ADHD, Anxiety Disorders
Disruptive to family, school, and peer group functioning
High incidence of suicide attempts, dangerous behavior, psychiatric hospitalizations.

Titanic Tantrums

Dillon's Behavioral Issues

Background:

8-year-old boy living with parents and younger brother
Exhibits explosive outbursts several times a day, last approximately 10 minutes
Destructive behavior during tantrums: kicked holes in bedroom door, bruises on mother's arms
Difficult child since birth, colicky baby, multiple tantrums per day as toddler

Symptoms:

Irritable and cranky for better part of the day
Agitated, restless, and expressed desire to be left alone
Attempts to cheer him up unsuccessful or worsened irritability
Hostile attributions regarding peers' intentions
Difficulty focusing, following instructions, and completing classwork
Highly distractible and fidgety
Opposition to routines, such as homework and daily tasks
Irritable mood worsened around first grade
Easily bothered by little things, constant crankiness for days at a time
Hostile reactions to perceived negative events
Mind spirals: difficulty controlling anger and staying upset for several hours

Impact on Life:

Suspended from school three times due to aggressive behavior
Academic struggles despite average cognitive abilities
Restricted family outings, avoided church attendance
Difficulty making friends, peers avoided him
Parents consulted child psychiatrist and received parent management training, individual cognitive-behavioral therapy for Dillon.

Diagnosis:

Disruptive Mood Dysregulation Disorder (DMRD) according to DSM-5
Symptoms: frequent temper outbursts, chronic irritable mood, impairment at home and school
Also meets criteria for Attention Deficit Hyperactivity Disorder (ADHD), Combined Presentation, and Oppositional Defiant Disorder (ODD) but only DMRD diagnosis assigned.
No signs of mania symptoms or episodic irritability in Bipolar Disorder.

4.2 Major Depressive Disorder

Major Depressive Disorder (MDD)

Criteria:

Periods of:
- Depressed mood
- Markedly diminished interest or pleasure in activities
Occurring for at least 2 weeks, most days
Four or more symptoms from the following list:
- Appetite/weight changes
- Sleep disturbances
- Psychomotor symptoms
- Fatigue/energy levels
- Worthlessness/guilt
- Cognitive symptoms
- Death/suicidal ideation

Symptoms:

Mild, Moderate, or Severe based on number of symptoms and impact on functioning
Can include psychotic features (mood-congruent or mood-incongruent)
Anxious distress
Mixed features (manic/hypomanic symptoms)
Melancholic features
Atypical features
Catatonia (rare, see Schizophrenia Spectrum and Other Psychotic Disorders)

Clinical Course:

Single Episode or Recurrent
Onset during pregnancy/postpartum period
Seasonal pattern
Partial Remission or Full Remission

Prevalence:

7% 12-month prevalence in the US
More common in young adults, women, and individuals with a history of trauma or abuse

Treatment and Prognosis:

Combinations of psychotherapy and medication (e.g., SSRIs, tricyclics)
Psychotic features require antipsychotics
Anxious distress makes treatment more difficult
Mixed features increase suicide attempt risk
Melancholic features may require somatic treatment
Atypical features require specific medications (avoid TCAs)
Catatonia requires electroconvulsive therapy
Peripartum onset has a better prognosis than other onsets
Seasonal pattern may respond to bright light therapy
Partial vs. Full Remission affects treatment approach and follow-up frequency

Additional Considerations:

Occurs in all cultures, but presentation and symptom severity can vary
Impairment ranges from completely incapacitating to mild
High suicide attempt and completion rates, especially with co-occurring BPD.

Worthless Wife

Connie Russo's Background and Depression:

Depressed and unable to concentrate since separation from husband Vincent 3 months ago
Married for 5 years, left him due to domestic violence and threats to their son
Daily arguments during marriage, resulting in bruises and a gun threat towards son
Obtained a court order of protection and relocated with her parents
High school and secretarial school graduate, worked as executive secretary before marriage
Close relationship with parents, many friends, popular in high school
Married Mr. Russo after 3-month courtship despite his cocaine use
Increasingly critical and irritable husband, refusal to allow family visits, marital therapy
Thrombophlebitis during pregnancy, husband's violence towards her increased after Anthony's birth
Husband's cocaine use, violent behavior led to depression, worthlessness, guilt, lack of social contacts

Ms. Russo's Condition:

Major Depressive Disorder (MDD) with persistent depressed mood
Symptoms include loss of interest and pleasure, worthlessness, trouble concentrating, poor appetite, weight loss, lack of energy, difficulty sleeping
Single Episode due to no prior episodes
Moderate severity affecting role as a mother and social functioning
Excellent response to treatment with medication and therapy
In Full Remission after 6 months
Observation necessary for monitoring recurrence.

Stonemason

Stonemason Stanley Kozlowski's Case

Background:

Previously healthy 55-year-old stonemason
Loss of appetite and weight loss over six months
Burning pain in chest, back, and abdomen
Believes he has fatal abdominal cancer
Agitated behavior, feelings of extreme unworthiness
No history of emotional disturbance or substance abuse

Symptoms:

Loss of interest and pleasure (depressive syndrome)
Insomnia, weight loss, worthlessness, thoughts of death
Delusion of having fatal cancer
Melancholic features: lack of reactivity, diurnal mood variation, early morning awakening, significant weight loss, marked psychomotor agitation

Diagnosis:

Major Depressive Disorder (MDD)
- Single Episode
- With Psychotic Features
- With Melancholic Features
Absence of manic episodes rules out Bipolar Disorder
Normal physical examination and laboratory findings rule out Depressive Disorder Due to Another Medical Condition
Absence of medication or substance abuse history rules out Substance/Medication-Induced Depressive Disorder
Psychotic features consist with depressive themes (disease and death) and noted as Mood-Congruent Psychotic Features
Melancholic features present: loss of pleasure in activities, lack of reactivity, diurnal mood variation, early morning awakening, significant weight loss, marked psychomotor agitation.
Final diagnosis: Major Depressive Disorder, Single Episode, With Mood-Congruent Psychotic Features, With Melancholic Features.

Three Voices

Haruki Takahashi's Case Study

Background:

23-year-old man admitted to hospital due to profunda loss of energy and mute behavior
Lived in Flushing, Queens, New York for several years after breaking up with girlfriend
Worked odd jobs but unable to pursue long-term goals
Went to California to change environment and find new job, but became frightened and paranoid
Diagnosed with Major Depressive Disorder (MDD) and psychotic features by psychiatrist

Symptoms:

Profunda loss of energy
Little appetite
Virtually no interest or pleasure in activities
Heard three distinct voices: a child's voice, woman's voice, man impersonating woman
Voices spoke about various subjects but did not focus on specific depressive themes
Paranoid behavior and bizarre hallucinations
Anorexia and 20-pound weight loss
Hypersomnia
Psychomotor retardation (paucity of speech)
Depressed mood
Loss of interest and pleasure in activities

Treatment:

Started on antipsychotic medication, olanzapine 5 mg/day, and antidepressant, nortriptyline 150 mg/day
No improvement for first two weeks
Reduced olanzapine dosage to 2.5 mg/day and eventually stopped entirely
Marked improvement in energy level by end of fourth week
Discharged home on nortriptyline 150 mg/day but no other psychotropic medication
Symptoms reappeared rapidly when he ran out of nortriptyline treatment
Good response to antidepressant and family history of mood disorder

Discussion:

Haruki's case raises questions about appropriate subclassification of Major Depressive Disorder (MDD) during recurrent episodes
DSM-5 considers a 2-month period with no or only mild symptoms as minimal amount of time for considering a new episode
Some clinicians might regard the rapid development of symptoms following discontinuation of medication as indicating continuation of original MDD episode.

It’s Typical?

Ms. Siegel's Case

Ms. Siegel, a 25-year-old single art student, was diagnosed with Major Depressive Disorder (MDD) based on her symptoms:
- Persistent depression for most of the past 2 months
- Changes in interests, eating, sleeping, energy level, and self-concept
- Symptoms causing significant distress and interfering with functioning
- Mood reacts positively to positive events
- Atypical features: weight gain, excessive sleep, leaden paralysis
Her diagnosis would be Major Depressive Disorder, With Atypical Features
Treatment options for atypical depression include:
- Selective serotonin reuptake inhibitor (SSRI) medications
- Monoamine oxidase inhibitor antidepressant medications (phenelzine or tranylcypromine)
Additional diagnosis of Panic Disorder was suggested due to her anxiety attacks, but more information is needed to confirm.

New Mom

Ms. Maria Jimenez's Case History

Personal Information:

30-year-old married woman
Gave birth to first child (male), via cesarean section
On maternity leave from research analyst job at mutual fund investment company
Discontinued sertraline medication for social anxiety 1.5 years prior to pregnancy

Symptoms:

Depressed mood with overeating, oversleeping, decreased energy, decreased concentration, and decreased interest in most activities (except baby and food)
No suicidal plans or intentions, but "taunting thought" of hurting herself
No concerns about harming son
Feels guilty, worried she is a "bad" mother and may not bond with baby
Low self-esteem
Unable to lose desired weight after pregnancy, feels "fat and ugly"
Strained relationship with husband due to new baby demands
Close relationship with mother, who often criticizes her

Diagnoses:

Major Depressive Disorder (MDD): With peripartum onset (symptoms appeared within 4 weeks of delivery)
Social Anxiety Disorder (SAD): Previously managed with sertraline, returned to some extent while unmedicated

Notes:

MDD symptoms: Depressed mood, loss of interest, increased appetite, hypersomnia, decreased energy, decreased concentration, guilt, and worries about self-harm
SAD history: Previously controlled with sertraline, returned to some extent without medication
Peripartum onset of MDD increases risk for postpartum episode

A Child Is Crying

Cindy's Case:

Background:

Age: 15 years old
Brought to mental health clinic by father due to concerns about depression and suicidal thoughts
History of family conflict, mother's mental illness (chronic "psychotic" behavior, mood swings), and upcoming divorce
Cindy has been feeling depressed for most days for 2 years with symptoms worsening in the past 6 months

Symptoms:

Depressed mood with low self-esteem and hopelessness
Feeling depressed almost every day, all day long
Loss of interest in school and social activities
Decline in grades from As to Bs and Cs
Tiredness, trouble sleeping, and staying awake
Anxiety, feeling "spacey and unreal"
Hearing a child crying for help
Suicidal thoughts
Previous consideration of self-harm (cutting wrists)

Diagnosis:

Persistent Depressive Disorder (DSM-5): most days for 2 years
Major Depressive Disorder (DSM-5): most recent 6-month period, single episode with mood-congruent psychotic features (hallucinations of a child crying)
Additional diagnosis of Persistent Depressive Disorder to indicate long-standing depression that has worsened in severity over time.

A Perfect Checklist

Billy's Case: Depression and Associated Disorders

Background:

7-year-old child in second grade
Bringed to mental health clinic due to unhappiness, frequent complaints of feeling sick
Lives with parents, younger brother, and grandmother
Never been very happy or wanted to play with other children
Complained about various physical problems since nursery school

Symptoms:

Somatic complaints have escalated in the last few months
Difficulty completing schoolwork, feels he has to do it over and over for it to be "perfect"
Worries about falling behind if allowed to stay home from school
Unable to do work once at school, feeling hopeless
Lies down saying he is too tired, no interest or enjoyment in playing
Diminished appetite, trouble sleeping and staying asleep
Suicidal thoughts (wanted to shoot himself)

Maternal Observations:

Mother feels Billy has never been really happy, but more depressed recently
Worried about Billy's frequent somatic complaints, prompting medical examination
Difficulty getting him ready for school in the morning due to his somatic complaints

Diagnostic Considerations:

Major Depressive Disorder (MDD): Symptoms of depression such as low mood, loss of interest, suicidal thoughts
Obsessive-Compulsive Personality Disorder (OCPD): Perfectionism and worrying about performance in school
Generalized Anxiety Disorder (GAD): Worry about school performance, somatic complaints, anxiety about parents' safety
Separation Anxiety Disorder (SAD): Distress when anticipating or experiencing separation from attachment figures, excessive worry about harm befalling them.

Somatic Symptoms:

Difficulty determining if they are manifestations of MDD or a Somatic Symptom Disorder

Birth History:

Mother was hypertensive during pregnancy and emotionally upset
Delivery was complicated due to increasing hypertension
Billy reportedly went into cardiac arrest at birth
Neonatal symptoms: projectile vomiting, nocturnal enuresis (bed-wetting)

Billy's Behavior:

Unable to finish symptom checklist, worried about having a "perfect" one
Insisted on taking the papers home to complete them
Cried and became upset when his mother was interviewed without him
Reluctant to go to school, fearful of separation from attachment figures.

The Mixed-Up Waiter

Andrew Weiglein's Case Study

Background:

Single white male, age 21 years
Referred to mood and anxiety outpatient clinic for diagnostic clarification and treatment recommendations
Chief complaint: "I am worried that I might lose my job because my performance has declined a lot over the past month"

Symptoms:

Feeling sad for no apparent reason for the past 4 weeks
Unable to identify a trigger for sadness, never happened before
Decreased motivation and enjoyment in working, socializing, and eating
Feeling hopeless, stuck working as a waiter
Self-esteem declined
No thoughts of self-harm or suicidal ideation
Poor quality of sleep, increased time in bed (8 to 14 hours)
Exhausted and "wired and tired" upon waking, low energy throughout the day
Significantly affected concentration:
- Mistakes at work, boss threatened dismissal
- Customers complained about overly chatty behavior
- Difficulty focusing, easily distracted
- Racing thoughts with unconnected ideas

Financial Concerns:

Accumulated over $10,000 of debt in a month through online purchases and poker playing
Previously frugal, no impulsive behaviors or substance use/sexual encounters
Increased online spending despite lack of energy and motivation

Psychiatric History:

Family history of depression (mother, maternal grandmother)
Father diagnosed with bipolar disorder or schizophrenia

Medication Prescriptions:

Zopiclone 7.5 mg for sleep
Lorazepam 1 mg as needed for anxiety

Evaluation Findings:

Sad mood, dysphoric appearance
Pressured speech with flight of ideas
Impulsive behaviors causing harm (online purchases, poker)
Manic-like symptoms: overly chatty, racing thoughts

Diagnosis:

Major Depressive Disorder (With Mixed Features)
- Indicated by sadness, lack of interest, hopelessness, difficulty concentrating
- Presence of manic-like symptoms justifies the specifier "With Mixed Features"
- Close monitoring required for antidepressant medication to prevent precipitation of a manic episode.

Rx Florida

Dr. Redland's Case:

Applied to a special depression treatment program at a university hospital in Boston due to recurring depressions for nine years, mainly during winters
First depression occurred after moving from Florida to Washington D.C. at age 21
Depressions returned every winter until applying to the program
Depression symptoms: lethargic, apathetic, irritable, pessimistic, worse in mornings, insomnia, craving for carbohydrates, weight gain (Bermuda vacation exception)
Associated depressions with latitude and weather
Previously treated with psychotherapy and tricyclic antidepressant desipramine 175 mg/day
Entered treatment program, maintained on desipramine and bright light therapy: 10,000-lumen light box for 30 minutes daily in the morning
Responded well to treatment, increased desipramine dosage to 250 mg/day during winter months and continued using lights
Remained free of depression for last four years, no longer in psychotherapy.

Diagnosis:

Major Depressive Disorder, Recurrent Episode (DSM-5, p. 160)
Seasonal Affective Disorder with Winter Pattern (DSM-5, p. 187)
- Depression begins in fall or winter and ends in spring
- Substantial number of seasonal episodes over nonseasonal ones throughout lifetime
Typical symptoms: weight gain, craving for carbohydrates.

Distinguishing Features:

Unusual for recurrent depressions to follow a clear seasonal pattern
Most patients with SAD are women and experience increased sleeping (hypersomnia) rather than disturbed sleep (insomnia).

4.3 Persistent Depressive Disorder (Dysthymia)

Persistent Depressive Disorder (Dysthymia)

Characteristics:

Depressed mood for most of the day, for more days than not
Chronic condition for at least 2 years (1 year for children and adolescents)
At least two additional symptoms: poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, feelings of hopelessness
Chronicity is the most important negative prognostic indicator

Diagnostic Criteria:

No Manic Episode, Hypomanic Episode, or Cyclothymic Disorder
Severity varies widely from mild to severe
Can be specified as: With Pure Dysthymic Syndrome (Dysthymic Disorder), With Persistent Major Depressive Episode, With Intermittent Major Depressive Episodes (With Current or Without Current)

Specifiers:

In Partial Remission
In Full Remission
Symptomatic specifiers: With Anxious Distress, With Mixed Features
Severity specifiers: Mild, Moderate, Severe

Longitudinal Patterns:

Persistent Depressive Disorder (chronic mild depression)
Major Depressive Disorder with chronic mild depression background
Severe chronic depression (meeting diagnostic requirements for Major Depressive Disorder every day for 2 years)

Age of Onset:

Early Onset: Before age 21 years
Late Onset: At age 21 years or older

Additional Considerations:

Individuals with Early Onset more likely to develop Personality Disorders and Substance Use Disorders
Chronicity of depression is a defining feature, severity can vary widely.

Junior Executive

Junior Executive: Isabella Garcia's Case

Background:

28-year-old junior executive referred for "supportive" treatment by a senior psychoanalyst
Obtained master’s degree in business administration, moved to California 1% years ago
Complains of being "depressed" and "hopeless" about her job, husband, and future
Previous extensive psychotherapy: analyzed for 3 years in college, behaviorist for 1% years during graduate school
Persistent feelings of depressed mood, inferiority, and pessimism since age 16 or 17
Academically decent but ruminates about "genuinely intelligent" students
Dated but never pursued men she considered "special," felt inferior and intimidated
Therapy helped but cannot remember a time without feeling depressed

Marital Issues:

Married man she considered reasonably desirable primarily for companionship
Criticized her husband's clothes, job, and parents
Husband found her rejecting, controlling, and moody
Felt she had made a mistake in marrying him

Occupational Challenges:

Assigned menial tasks at firm, never given assignments of importance or responsibility
Often does "slipshod" job, demonstrates no assertiveness or initiative to supervisors
Views boss as self-centered and unconcerned
Feels she will never go far in her profession due to lack of connections for herself and her husband
Dreams of money, status, and power

Social Life:

Socializes with other couples through her husband's friends
Believes women find her uninteresting and unimpressive, men who like her are no better off than she is
Dissatisfaction with marriage, job, and social life leads to depression and loss of interest/energy

Diagnosis:

Persistent Depressive Disorder (Dysthymia)
Early onset in adolescence
No evidence of manic or hypomanic episodes, psychotic disorder, substance abuse, or medical condition
With Pure Dysthymic Syndrome

Additional Considerations:

Some clinicians may consider her depressive symptoms an expression of a Personality Disorder rather than Depressive Disorder.

Busted Nerves

Case Presentation: Norma Jean Luby

Background:

Referral for depression evaluation by primary care physician
Housewife, 49 years old
Appeared timid, dependent, helpless, and hopeless
Speech was slow and soft, sometimes inaudible
Claimed to have been ill all her life, with "busted nerves"

Symptoms:

Multiple complaints of pain (black ankles, neck knots, busted discs)
Gastrointestinal and respiratory complaints
Depressed since childhood
Difficulty paying attention, forgetfulness
Hears voices calling her name, fearful
Smothering episodes with dizziness, racing heart, tingling hands

History:

No formal psychiatric evaluation or treatment history
Tried minor tranquilizers with no benefit
Born and raised in central Appalachia
Attended school through 8th grade, unable to learn
Stayed at home to help mother and father
Married at age 23, three grown daughters
Husband draws disability for black lung disease

Therapy and Diagnosis:

Seen for individual supportive psychotherapy and medication management
Chronic symptoms with little insight into condition
Tried various medications, with trazodone showing some improvement in sleep
Diagnosis: Persistent Depressive Disorder (Dysthymia) with Early Onset
- Depression since childhood
- Hopelessness, lack of energy, insomnia, poor appetite, and concentration
Additional diagnosis considerations: Somatic Symptom Disorder or Panic Disorder
- Somatic symptoms attributed to "nerves" rather than specific causes
- Fainting, paralysis, forgetfulness, inertia, and inability to do strenuous activity
Personality Disorder diagnosis not apparent based on symptoms.

Disabled Vet

Mr. Albrecht's Background and Conditions:

Personal History:

37-year-old man admitted to VA hospital after suicide attempt
Depressed since returning from Iraq 10 years ago, with no specific trigger
Normal childhood and adolescence: friends, average grades, never in trouble with the law
High school graduate; trained as electrician; joined Army Reserves
Called up for military service in Iraq
Loathed violence but killed a civilian "for fun"; haunted by guilt
Honorably discharged from army after extended tour
Lived on various forms of government assistance since then

Behavioral Patterns:

Began heavy drinking and drug use in the army
Turned to alcohol exclusively 10 years ago
Heavy, continuous drinking with blackouts, frequent arrests, injuries
No friends, only acquaintances
Depressed when others enjoy themselves
Attempted suicide multiple times
Lived in an alcohol treatment residence for a month before hospitalization

Medical Condition:

No evidence of delusions or hallucinations except during withdrawal episodes
Normal appetite and sex drive, but lacks enjoyment
Difficulty sleeping without medication
Affected by peripheral neuropathy (weakness, numbness, pain in hands and feet)
Impaired immediate and long-term memory, agnosia, apraxia, constructional difficulties
IQ measured at 66

Diagnoses:

Persistent Depressive Disorder (Dysthymia) with severe depression
Severe Alcohol Use Disorder
Alcohol-Induced Major Neurocognitive Disorder

4.4 Premenstrual Dysphoric Disorder

Premenstrual Dysphoric Disorder (PMDD)

Definition:

Diagnosed under DSM-5 for women experiencing significant emotional and physical symptoms during menstruation cycle
Symptoms must be present in the final week before menses, improve within a few days after onset of menses, and be minimal or absent in the postmenstrual week

Symptoms:

Group 1: Affective Lability
- Sudden changes in mood
- Marked irritability or anger
- Increased interpersonal conflicts
- Depressed mood, feelings of hopelessness, self-deprecating thoughts
- Anxiety, tension, feeling keyed up or on edge
Group 2: Symptoms of Depression
- Decreased interest in activities
- Difficulty concentrating
- Lethargy or lack of energy
- Marked change in appetite (overeating, craving specific foods)
- Hyperactivity or insomnia
- Sense of being overwhelmed or out of control
- Physical symptoms: breast tenderness/swelling, joint/muscle pain, bloating, weight gain

Diagnosis:

Minimum of five total symptoms required
At least one symptom from each group must be present
Symptoms must be associated with the menstrual cycle and follow a specific pattern

Prevalence:

Estimated 1.8% to 5.8% prevalence in menstruating women
Can begin at any time after menarche, worsens as woman approaches menopause

Differentiation from Premenstrual Syndrome:

Premenstrual syndrome is less severe and does not include prominent affective symptoms

Impact on Functioning:

Significant distress and impairment in psychosocial functioning
Not merely an exacerbation of another mental disorder or attributable to physiological effects or substances.

4.5 Depressive Disorder Due to Another Medical Condition

Depressive Disorder Due to Another Medical Condition

Diagnosis:

Depressive Disorder Due to Another Medical Condition

Symptoms:

Prominent and persistent period of depressed mood or markedly diminished interest or pleasure in all or almost all activities
Direct pathophysiological consequence of another medical condition

Supporting Evidence:

Clinical history
Physical examination
Laboratory tests

Relationship to Underlying Medical Condition:

Establish etiological relationship between depression and medical disorder
Temporal association between onset, exacerbation, or remission of mood disturbance and change in course of medical disorder

Characteristics of Depressive Disorder Due to Another Medical Condition:

Can be noted via specifiers:
- With Depressive Features (if full criteria for Major Depressive Episode not met)
- With Major Depressive—Like Episode (if full symptomatic criteria for Major Depressive Episode are met)
- With Mixed Features (if symptoms of mania or hypomania along with depressive symptoms)

Case Study: Toy Designer

Ray McKenzie, 45-year-old toy designer admitted to hospital after suicidal gestures and attempt to strangle himself
Depressed mood, suicidal gestures, increased sleep, loss of interest, and guilt suggest past episode of Major Depressive Disorder
Infer that presurgical disturbance is caused by frontal-lobe brain tumor, diagnosis: Depressive Disorder Due to Brain Tumor
Post-surgery, predominant disturbance is apathy and indifference rather than depression, diagnosis: Personality Change Due to Brain Tumor, Apathetic Type.

CHAPTER 5 Anxiety Disorders

Anxiety Disorders:

Characterized by excessive fear or anxiety
Resulting in avoidance behaviors to mitigate the anxiety
Normal Part of Life: Fear is essential for protection, while anxiety is a future-oriented affective state
Abnormal: Fear or anxiety can occur without realistic threat or be out of proportion to danger
Types: Separation Anxiety Disorder, Selective Mutism, Specific Phobia, Social Anxiety Disorder (Social Phobia), Panic Disorder, Agoraphobia, and Generalized Anxiety Disorder

Separation Anxiety Disorder:

Developmentally inappropriate and excessive fear or anxiety concerning separation from attachment figures
Minimum duration: 4 weeks in children, 6 months in adults

Selective Mutism:

Consistent failure to speak in social situations where speaking is expected

Specific Phobia:

Marked fear or anxiety about a specific object or situation (e.g., dogs, snakes, heights, flying)

Social Anxiety Disorder (Social Phobia):

Marked fear or anxiety about social situations involving scrutiny by others

Panic Disorder:

Recurrent unexpected panic attacks with abrupt surges of intense fear or physical discomfort

Agoraphobia:

Marked fear or anxiety about multiple specific situations (public transportation, open spaces, enclosed places, standing in line, being alone outside)
Fear or avoidance of situations due to difficulty escaping or help in case of incapacitating or embarrassing symptoms

Generalized Anxiety Disorder:

Excessive anxiety and worry about a number of events or activities for at least 6 months

Anxiety Disorder Due to Another Medical Condition:

Anxiety or panic attacks that are the direct pathophysiological consequence of another medical condition.

5.1 Separation Anxiety Disorder

Separation Anxiety Disorder

Description:

Excessive fear or anxiety about being separated from attachment figures
Distress may be experienced upon separation or in anticipation of it
Individual worried about harm befalling attachment figure
Fears expressed directly or indirectly, e.g., refusal to leave home, go to school

Characteristics:

Persists for at least 4 weeks in children, 6 months in adults
Most prevalent Anxiety Disorder in children under age 12 years
Decreases with age, not all children who have it become adults with pathological anxiety
Affects both boys and girls but presentation may differ: girls more likely to engage in school refusal or avoidance; boys more likely to express anxiety indirectly.

Causes:

Onset often follows a stressor, such as parental divorce, natural disaster, family death, illness, move, immigration, or death of a pet
In adults: moving out of the family home, romantic involvement, becoming a parent

Symptoms:

Refusal to go to school (school refusal or avoidance)
Reluctance to leave home
Somatic complaints, e.g., headaches, tummy aches, vomiting
Anger and irritability
Fear that something bad will happen while separated from attachment figures

Case Study: Tiny Tina

10-year-old girl with school refusal or avoidance
Began when she cried and hid in the basement on first day of school
Attended only if parents took her, dressed and fed her, and drove her there
Eventually admitted that leaving home was behind her reluctance to go to school.

Diagnosis:

Separation Anxiety Disorder (DSM-5)
Characterized by excessive distress about separation from family, unrealistic worry about harm befalling attachment figures, and complaints of physical symptoms on school days lasting more than 4 weeks.

5.2 Selective Mutism Selective

Selective Mutism:

Definition: Consistent failure to speak in specific social situations where expectation for speaking exists (DSM-5, p. 195)
Symptoms:
- Child continues to speak in other situations
- Refusal to speak interferes with educational achievement and development of social skills
- Most common during entry into school system
Associated Conditions:
- Specific Phobia (fear of animals, etc.)
- Separation Anxiety Disorder
- Mild Communication Disorders or physical disorders that interfere with articulation
Diagnosis: Not due to lack of familiarity with language or Communication Disorders like Childhood-Onset Fluency Disorder (Stuttering) or Autism Spectrum Disorder.

Case Study: Quiet Kevin:

6-year-old first grader refusing to speak in school or any social situations
Initially whispered to mother during evaluation but wouldn't speak to interviewer
Good mood and broad affect, but looked frightened at expectation of speaking
Loved going to parties, playing with others, and singing, but would not converse
No history of medical problems or avoidance of social situations or strangers
Previously treated with behavioral therapy and fluoxetine antidepressant with minimal improvement
Gradual discontinuation of medication led to return of mutism, less exuberant mood, and more oppositional behavior at home
Voted president of class after speaking to everyone except teachers who knew him as a mute kindergartner.

5.3 Specific Phobia

Specific Phobia

Intense fear and anxiety related to an object or situation (phobic stimulus)
Avoidance attempts due to intense fear or anxiety
Persistent, lasting at least 6 months
Significant distress or impairment in functioning
Wide range of phobic stimuli: Animal, Natural Environment, Blood-Injection-Injury, Situational, Other
- Social Anxiety Disorder diagnosed separately (Section 5.4)
Onset may follow traumatic event, media coverage, or unexpected panic attack
Common disorder: approximately 7%-9% in the U.S., higher prevalence for women.

Specific Phobia Symptoms:

Increased heart rate, blood pressure, and sweating during exposure to feared object/situation
Vasovagal fainting or near-fainting response for Blood-Injection-Injury type
Common disorder: approximately 7%-9% in the U.S., higher prevalence for women.

Thunderstorms

Ms. Sheila Antonelli's Fear of Thunderstorms

Background:

28-year-old housewife with a fear of storms since childhood, became more distressing over the years
Frightened by lightning but unsure why
Anxiety increases days before a storm even if weather is only overcast
Seeks treatment due to fear passing it on to her children and impact on daily life

Symptoms:

Persistent fear of thunderstorms
Distressing level of anxiety during storms
Avoidant behavior: planning visits, staying at relative's house, covering eyes or moving away from windows
Impact on routine: interferes significantly with normal activities

Diagnosis:

Specific Phobia (DSM-5, p. 197) due to excessive fear and functional impairment

Childhood Origins:

Fear goes back to childhood
Developed through "modeling" from another family member

Features of Specific Phobia:

Distressing level of anxiety during storms
Avoidant behavior
Interferes significantly with daily life.

Stay Healthy

Mr. Michaels' Fear of Bodily Injury or Illness

Background:

27-year-old computer programmer
Afraid of situations related to bodily injury or illness
Cannot bear to have blood drawn, see sick people, or hear about medical procedures
Avoids visiting doctor and friends with illnesses
Fainted during a leg operation description in Sunday school at age 9
Difficulty receiving immunizations and undergoing routine medical procedures throughout childhood and adolescence
Numerous fainting episodes when witnessing physical trauma or hearing about injuries

Recent Incident:

Unable to visit terminally ill father-in-law in the hospital due to fear
Fainted when seeing someone in a wheelchair, believing they might be in pain

Distinguishing Features:

Not related to obsession with germs (OBS-COPD) or prior traumatic experience (PTSD)
Physiological response: initial period of arousal followed by vasovagal drop in heart rate and blood pressure, leading to fainting

Other Related Disorders:

Illness Anxiety Disorder (IAD): preoccupation with having or acquiring serious illnesses like cancer; high general anxiety about health; contrasts from Specific Phobia as primary symptoms are not fear, anxiety, and avoidance related to phobic stimulus.

5.4 Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder (Social Phobia)

Significant Fear or Anxiety:

About being in a social situation where one is exposed to the scrutiny of others
The social situation may involve:
- Performance in front of a group (e.g., giving a speech)
- Being observed in public (e.g., eating or drinking)
- Meeting new people or engaging in conversation with others

Person with Social Anxiety Disorder:

Afraid that they will act in a way that is embarrassing, humiliating, offending, or provoking rejection by others
Fears the situation and either avoids it or endures it with dread
Anxiety or avoidance is not related to another mental disorder (e.g., Panic Disorder, Body Dysmorphic Disorder)
Distressing anxiety may be due to an underlying medical condition with embarrassing symptoms

Diagnosis and Prevalence:

Diagnosis should only be given if the fear and avoidance is out of proportion to the symptom in question
Social Anxiety Disorder is one of the more common Anxiety Disorders, with a 12-month prevalence estimate in the U.S. of approximately 7%
Onset is usually in early adolescence, with a waxing and waning course that may last for several years or more
Women are somewhat more affected than men, although men may be more likely to seek treatment

Mail Sorter

Patient Profile: Andy Johnson

Demographic Information:

Age: 25 years old
Gender: Male
Living Situation: Lives with mother and brother

Occupational History:

Mail sorter at the post office
Previously dropped out of college after 2 years

Presenting Complaints:

"Nervousness" and feeling of "just going through the motions"
Desire to lead a normal life and go back to college

Historical Background:

No close friends during adolescence and young adulthood, preferred to be alone
Formed several friendships in college but became self-conscious when speaking to strangers or classmates
Experienced "panic attacks" with symptoms of nervousness, stiff face, buzzing in head, feeling disconnected from body, hot flashes, and sweating
Attacks occurred only when with people and not during solitary activities
Dropped out of college due to social anxiety

Current Coping Mechanisms:

Avoids using public bathrooms, feels more comfortable in dimly lit rooms or with fewer people present
Has two "best friends" with whom he socializes regularly and feels completely comfortable
Avoids dating and group settings (e.g., weddings, parties, clubs)
Has no problem with authority figures and welcomes constructive criticism from supervisor at post office

Diagnostic Considerations:

Social Anxiety Disorder: Anxiety occurs in a variety of social situations where the patient fears doing or saying something humiliating or embarrassing
Avoidant Personality Disorder: Symptoms meet criteria for this disorder, including avoidance of activities involving interpersonal contact, inhibition in interpersonal situations, preoccupation with being criticized or rejected, and feelings of inadequacy.

On Stage

Doug Phillips' Case:

Doug Phillips is a 33-year-old man living in Seattle, employed as a salesperson for an insurance company since college graduation
Anxiety at work: college anxiety returned during third year
- Nervousness during tests and writing papers
- Heart pounding, hands sweating and trembling
- Affected grades negatively
Sales career: anxiety returns when expected to perform
- Nervousness before answering business phone calls
- Avoids scheduling appointments with clients
- Concerned about what clients might think if they sense his nervousness
- Repeatedly rewrites sales scripts
Functioning at only 20% capacity, borrowing large sums of money for living expenses
Socializing abilities unaffected except during work situations

Diagnosis: Social Anxiety Disorder (SAD) - Performance Only type

Symptoms:

Marked and persistent fear of social or performance situations
Exposed to unfamiliar people or possible scrutiny from others
Fear that he would act in a way that will be humiliating or embarrassing
No anxiety in non-performance situations
Limited to specific phobic stimulus (phone conversations)

Discussion: Mr. Phillips' problem is crippling anxiety when he feels he's performing, which includes college tasks and work performances but not social activities. The fear of being judged and feeling foolish are key symptoms of Social Anxiety Disorder, specifically the Performance Only type.

No Friends

Social Anxiety Disorder (Emily's Case)

Background:

7-year-old girl named Emily
Reluctance to interact with peers
Difficulty responding to other children
No friends in classroom
Discomfort around unfamiliar people

Symptoms:

Shy and nervous with peers
Cries or shakes when introduced to new children
Never invited to birthday parties
Warm and outgoing with family

Diagnosis:

Social Anxiety Disorder (DSM-5, p. 202)
Fear of humiliating or embarrassing situations
Diagnosis not appropriate for Personality Disorder due to age.

Previous Teachers' Concerns:

Emily was very withdrawn and nervous with other children since kindergarten
Teachers had commented on her report cards about her behavior

Mother's Efforts:

Tried repeatedly to get Emily involved with neighbors' children
Led Emily by the hand to meet new kids but she would cry or shake

Current Situation:

No improvement in social skills after 6 months into second grade.

Additional Information:

Emily's behavior is different with her family, who she is warm and outgoing towards
In an adult, this behavior may suggest Avoidant Personality Disorder but not appropriate for a child diagnosis.

5.5 Panic Disorder

Panic Disorder

Symptoms:

Sudden, unexpected attacks of extreme fear or anxiety
Symptoms may include: palpitations, accelerated heart rate, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, chills or hot flashes, and numbness/tingling in extremities
Disturbing perceptions or cognitions during attack: derealization, depersonalization, fear of losing control, going crazy, or dying
Persistent concern or worry about additional attacks
Behavioral changes to avoid perceived triggers (e.g., traveling on public transportation, crowds)

Statistics:

Relatively common with a 12-month prevalence in the general population of approximately 2%-3% in adults and adolescents
Onset usually in early 20s
Chronic course without treatment but waxing and waning symptoms
More likely to affect women than men

Case Study: Ms. Markowitz's Experience

Panic attacks began with sudden intense fear, no apparent cause
Symptoms included trembling, nausea, sweating, choking, fear of losing control or going crazy
Attacks started in high school during stressful times (sneaking around parents, pressure from work and college applications)
Intermittent attacks over 8 years with variations in intensity
Functioned well in school, work, and social life despite attacks
Never associated attacks with particular places, always "toughed it out"

Diagnosis:

Panic Disorder (DSM-5, p. 208)
No symptoms of Agoraphobia as no specific triggers identified.

I Could Be Dying

Background:

Niyol Begay: 52-year-old wholesale distributor with sleep disturbances and panic attacks
Woke up multiple times a week gasping for breath, sweating, shaking, and having palpitations
Third attack in a week and tenth that month
History of recurrent panic attacks since age 12
Attacks began occurring during sleep after turning 50
Previously drank 8-10 beers every weekend for years but stopped due to weight loss and hypertension improvement

Symptoms:

Difficulty breathing, sweating, shaking, rapid heartbeat, palpitations (panic attacks)
Anxiety in anticipation of certain situations (elevators, planes)
Fear of falling apart without "support system" (beer cooler)
Avoidance of uncomfortable situations and flights

Diagnosis:

Panic Disorder: recurrent unexpected panic attacks with characteristic symptoms and fear of consequences
Agoraphobia: avoidance of places or situations that may trigger panic attacks
Insomnia Disorder: persistent insomnia causing daytime fatigue, distress or impairment in functioning.

Additional History:

Successful businessman but anxiety prevented accepting a large government contract due to fear of scrutiny and long plane flights
Two sisters and two daughters suffer from agoraphobia
No evidence for Obstructive Sleep Apnea despite symptoms like snoring, weight loss, hypertension improvement.

5.6 Agoraphobia

Definition: Marked fear or anxiety triggered by real or anticipated exposure to a variety of situations, including:

Using public transportation (e.g., automobiles, buses, trains, ships, or planes)
Being in open spaces (e.g., parking lots, markets, bridges)
Being in enclosed spaces (e.g., shops, theaters)
Standing in line or being in a crowd
Being outside of the home alone

Characteristics:

Fear or avoidance of at least two of the above situations
Consistently provokes fear or anxiety in the individual
Active avoidance or endurance with intense fear or anxiety
Persistent, lasting for at least 6 months
Causes significant distress or impairment in functioning
Not given if attempts to avoid a situation would be considered reasonable due to inherent danger

Statistics:

Relatively common, with an estimated 12-month prevalence in the general population of adults and adolescents of approximately 1.7%
Typical onset is in late adolescence or early adulthood
Women are twice as likely to be affected as men
Course is typically chronic without treatment, very few have spontaneous remissions

Comorbidities:

Other Anxiety Disorders
Depressive Disorders
Substance Use Disorders
Personality Disorders

Case Study: "No Fluids"

Ms. O'Reilly, a 32-year-old medical secretary in Dublin, Ireland, was referred for treatment of depression
Fearful that she will urinate in public, even though she has never actually done so
Avoids activities like work, traveling far from home, and drinking alcohol to prevent this fear
Has a history of anxiety and overly cautious behavior
Treatment with clomipramine (an antidepressant medication) and a behavioral program helped her manage the condition
Moved away from her mother and ended her relationship with her boyfriend's tension, leading to continued improvement.

5.7 Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD)

Characteristics:

Excessive anxiety and worry for most of the time over a period of at least 6 months
Restlessness or feeling keyed up or on edge
Easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance

Symptoms:

Worry about routine life circumstances: job responsibilities, health, finances, family members' health, children's competence, etc.
Inability to control the worry
Constant feeling of being "edgy" or watchful, interfering with concentration

Diagnosis:

Not attributable to physiological effects of a substance or medical condition
Not better explained by another mental disorder (e.g., Obsessive-Compulsive Disorder)

Prevalence and Onset:

12-month prevalence in the general population: approximately 0.9% for adolescents, 2.9% for adults
Onset usually around age 30
Women are twice as likely as men to have the disorder
Chronic course with waxing and waning symptoms across the lifespan

Case Study: "Edgy Electrician" (Mr. Schmidt)

Symptoms of excessive anxiety and worry for more than 2 years
Predominant symptoms: feeling on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
Worry about the health of his parents, being a good father, wife leaving him, coworkers' opinions
Recognizes his worries are often excessive and repetitive but cannot control them
Has few social contacts due to nervous symptoms
Continues to work despite hiding symptoms from family.

5.8 Anxiety Disorder Due to Another Medical Condition

Anxiety Disorder Due to Another Medical Condition

Symptoms:

Anxiety or panic attacks that are a direct pathophysiological consequence of another medical condition
Examples:
- Pheochromocytoma (benign tumor of the adrenal gland that secretes norepinephrine)
- Vitamin B12 deficiency (pernicious anemia)

Diagnosis:

Requires evidence from history, physical examination, or laboratory testing of a medical condition known to cause anxiety
Evidence of temporal association between onset/exacerbation/remission of medical condition and anxiety symptoms
Atypical features that differ from typical anxiety disorders (e.g., unusual age at onset)
Documented physiological mechanisms linking medical condition to anxiety

The Outdoorsman Case Study:

78-year-old retired lumber company president with episodic attacks of apprehension, restlessness, and need to be outdoors
Temporal association between attack onset and subzero weather (relief with outdoor exposure)
No shortness of breath, palpitations, or other typical anxiety symptoms
Symptoms included trembling, sweating, dizziness, and fear of dying/losing consciousness
Balance problem and intermittent right arm pain
Diagnosis: Vitamin B12 deficiency (pernicious anemia)
Corrected with vitamin replacement, attacks did not recur

Conclusion:

Differentiating anxiety disorders from anxiety due to medical conditions requires careful examination and consideration of physiological mechanisms.

CHAPTER 6 Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive and Related Disorders (OCD)

Characteristics:

Difficulties controlling cognitive processes (thinking, perceiving) and behaviors
Preoccupying and endlessly repetitive thoughts, urges, or images (obsessions)
Recurrent and persistent anxiety or distress caused by obsessions
Repetitive behaviors or mental acts in response to preoccupations (compulsions)

Types:

Obsessive-Compulsive Disorder (OCD): Obsessions and compulsions
Body Dysmorphic Disorder: Preoccupation with perceived physical flaws
Hoarding Disorder: Persistent difficulty discarding possessions, accumulation of items congesting living areas
Trichotillomania (Hair-Pulling Disorder): Recurrent pulling out of hair
Excoriation (Skin-Picking) Disorder: Repetitive skin picking resulting in lesions

Insight:

With Good or Fair Insight: People recognize beliefs may not be true, behavior is problematic
With Poor Insight: People think their beliefs are probably true, behavior is not problematic despite evidence to the contrary
With Absent Insight/Delusional Beliefs: No insight or delusional beliefs, completely convinced of truth and no problem with behaviors.

6.1 Obsessive-Compulsive Disorder

Obsessive-Compulsive Disorder (OCD)

Themes of Obsessions and Compulsions:

Cleaning:
- Repetitive thoughts about possible contamination by dirt, germs, or disease
- Compulsory cleaning behaviors such as excessive hand washing
Symmetry:
- Repetitive thoughts about order
- Behaviors involving repeating, ordering, and counting
Forbidden Thoughts:
- Aggressive, sexual, or religious thoughts and behaviors
- Such as praying
Harm:
- Fears of harm to self or others
- Compulsory checking behaviors to ensure safety or security

Characteristics of Obsessions and Compulsions:

Obsessions cause anxiety or distress
People struggle to ignore, suppress, or "neutralize" obsessions with other thoughts or actions (compulsions)
Compulsions are repetitive behaviors or mental acts felt "driven" to perform
Not connected in a realistic way to what they are intended to neutralize or prevent
Often odd, irrational, and have a "magical" component
Distinguish from worries about real-life concerns

Onset of OCD:

Usually begins in late adolescence but may start earlier or in childhood
12-month prevalence in the US is 1.2%
Slightly more common in women than men in adulthood, but more common in boys than girls in childhood

Impact of OCD:

Can cause significant impairment and interfere with daily life
People may avoid people or situations that trigger symptoms
Up to 25% attempt suicide at some point
If untreated, course can be chronic with little chance of complete recovery
Often co-occurs with other mental disorders such as Anxiety, Depressive, Tic, and Personality Disorders.

Lady Macbeth

Cindy's Experience with Obsessive-Compulsive Disorder (OCD)

Description of Cindy's Condition:

Severe form of OCD as described in DSM-5 (p. 237)
Both obsessions and compulsions present, causing distress and interfering with functioning
Onset in adolescence

Obsessions:

Contamination: fear of germs on clothes, dreaded events (grandmother becoming sick)
Intrusive, unwanted thoughts that require neutralization through compulsions

Compulsions:

Repetitive behaviors to prevent discomfort or feared event
Rigidly applied rules (saying "soap and water" to cancel out germ words)
Extreme measures: washing hands for hours, leading to bleeding

Insight and Awareness:

Cindy recognizes irrationality of fears intellectually but emotionally reacts as if they are real
Good insight in this case (With Good or Fair Insight specifier)
No hallucinations, only intrusive thoughts confused with auditory hallucinations

Associated Conditions:

Occasionally Obsessive-Compulsive Personality Disorder may be present but not diagnosed in this case
Major Depressive Disorder can occur before or during OCD and increase suicide risk
Cindy experienced an episode of Major Depressive Disorder early on in her OCD.

6.2 Body Dysmorphic Disorder

Body Dysmorphic Disorder (BDD)

Definition: Preoccupation with perceived defects or flaws in physical appearance that are not observable or appear slight to others.

Symptoms:

Repetitive behaviors: checking appearance, grooming, seeking reassurance, comparing to others
Feelings of ugliness, unattractiveness, abnormality, deformity
Commonly affects skin, hair, nose but can involve any body part
Diagnosis may overlap with Eating Disorders (Anorexia Nervosa or Bulimia Nervosa)
- Body image distortions are a feature of Eating Disorder
- Individuals without Eating Disorder can have an additional diagnosis of BDD if preoccupations are impairing

Onset: Often begins in adolescence

Prevalence: 2.4% in the United States, slightly more common in women

Types and Occurrences:

Muscle dysmorphia: exclusive to men, preoccupation with body being too small or insufficiently muscular
High prevalence in dermatology, cosmetic surgery practices
Chronic disorder, often leads to unnecessary treatments or surgery

Impact: Impairing, can avoid social situations, drop out of school or work, become housebound due to concerns about appearance.

Elephant Man

Patient Profile: Marco Caruso

Background:

31-year-old carpenter
Shy, anxious-looking
Hospitalized after suicide attempt
No friends, recently fired from job, left by girlfriend

Appearance:

Wears baseball cap to cover eyes and hide perceived flaws
Preoccupied with a perceived defect in appearance

Behavior:

Avoids brightly lit rooms
Spends hours looking at marks in mirror
Missed work due to anxiety about appearance
Attempted suicide twice

Perception of Self:

Believes he has huge, ugly pockmarks on nose that make him look like "The Elephant Man"
Embarrassed by perceived flaws
Distorted self-image leads to significant distress and impaired functioning

Diagnosis:

Body Dysmorphic Disorder (DSM-5, p. 242)

Symptoms:

Preoccupation with a facial flaw or perceived defect
Repetitive behaviors: excessive mirror checking, camouflaging grooming activities, wearing hats/masks, questioning others about the "defect"
Poor insight into imagined or distorted nature of the perceived flaw
Degree of insight may vary from good to delusional.

Impact on Life:

Significant impairment in occupational, social functioning
Suicide attempts not uncommon
Distress and dysfunction span a spectrum of severity.

6.3 Hoarding Disorder

Hoarding Disorder

Hallmark: Persistent difficulty discarding or parting with possessions, regardless of their actual value
Individuals hold on to items because of perceived need for future utility, aesthetic or sentimental value
Commonly saved items: newspapers, magazines, old clothing, bags, books, mail, paperwork, animals
Accumulation leads to congestion and compromise of active living space
Living areas may become unsafe due to fire, falling, or respiratory/disease risks
Symptoms often begin in adolescence, increase with age
Prevalence estimates: 2%-6% in US and Europe
More common in men, but women seek treatment more frequently

Case Study: Eli Wolfe

Hoarding disorder diagnosis
Persistent difficulty parting with possessions
Accumulation leads to uninhabitable living conditions
Disrupted personal life (divorce, job losses)
Long-standing problem with inability to throw things out
Hoarding behavior not part of Obsessive-Compulsive Personality Disorder or Schizophrenia
Anxiety associated with thought of discarding items, but not intrusive and unwanted obsessions
Failure to engage in appropriate behavior rather than repetitive stereotyped hoarding behavior.

6.4 Trichotillomania (Hair-Pulling Disorder)

Trichotillomania (Hair-Pulling Disorder)

Essential Features:

Recurrent pulling out of one's hair, resulting in hair loss
Repeated attempts to decrease or stop hair pulling

Characteristics:

Hair can be pulled from any part of the body, most commonly scalp, eyebrows, eyelids
Episodes can be brief and sporadic or prolonged and enduring
Causes great distress, including embarrassment, shame, feeling out of control
Triggered by negative emotions (e.g., boredom, anxiety) and accompanied by increased tension before pulling
Leads to sense of pleasure or relief once the behavior has occurred
Individuals may attempt to hide hair loss with hats, scarves, or wigs

Prevalence:

1%-2% 12-month prevalence in adults and adolescents
Women are 10 times more likely than men to have Trichotillomania
Onset most commonly at puberty

Symptoms:

Hair pulling often interferes with social and occupational functioning
Occasionally associated with physical problems (e.g., skin infections)

Case Study: Celeste Nguyen

Experienced hair pulling since age 12, primarily on scalp and eyebrows
Bald patches on head, sometimes practically bald for a period
Carefully hid the behavior through brushing, scarves, and wigs
Hair picking was a daily habit, often lasting up to an hour
Prescribed antidepressants (fluoxetine and clomipramine) which improved symptoms
Also received hypnosis treatment
Continues to attend self-help group for ongoing support

6.5 Excoriation (Skin-Picking) Disorder

Excoriation Disorder

Characteristics:

Recurrent skin picking resulting in skin lesions (DSM-5, p. 254)
Individuals repeatedly attempt to decrease or stop picking
Most commonly picked sites: face, arms, hands
Skin picking consumes hours of the day and may persist for months or years
Causes significant distress including embarrassment, shame, feeling out of control
Triggered by negative emotions (boredom, anxiety), tension before picking, sense of pleasure or relief after
Individuals may hide lesions with makeup or clothing
Lifetime prevalence: 1.4%
Women outnumber men by about 3 to 1
Onset most commonly at puberty, often begins with acne
Usually chronic, interferes with social and school/work functioning
Physical problems: tissue damage, scarring, infections; may require treatment with antibiotics or surgery

Case Study: Shelley Kellerman

28-year-old single woman who picks at her skin
Began picking at acne around age 13
Increased frequency and intensity during college under stress from examinations
Picks daily for the past 4 years, usually after showering or before bedtime
Picks with fingernails, spends approximately 3 hours each day picking
Embarrassed by behavior, ashamed and embarrassed after each episode
Urge to pick is irresistible, feels unable to resist the drive
Avoids social activities (swimming, shorts) due to scarring from picking
Does not want to explain situation due to embarrassment
Frequent tardiness for work or missed appointments
Scans environment for things to pick, even on boyfriend's skin
Seeks help but has difficulty finding understanding professionals.

CHAPTER 7 Trauma- and Stressor- Related Disorders

Trauma- and Stressor-Related Disorders (DSM-5)

Characteristics of Trauma- and Stressor-Related Disorders:

Reactive Attachment Disorder: inhibited, emotionally withdrawn behavior toward adult caregivers; extremes of insufficient care responsible for disturbed behavior
Disinhibited Social Engagement Disorder: child actively approaches and interacts with unfamiliar adults; extremes of insufficient care responsible for disturbed behavior
Posttraumatic Stress Disorder (PTSD): exposure to actual or threatened death, serious injury, or sexual violence; intrusion symptoms associated with the traumatic event, persistent avoidance of stimuli, negative alterations in cognition and mood, marked alterations in arousal and reactivity; duration of disturbance more than 1 month
Acute Stress Disorder: exposure to actual or threatened death, serious injury, or sexual violence; presence of symptoms of intrusion, negative mood, dissociation, avoidance, and arousal after the traumatic event; duration of disturbance 3 days to 1 month
Adjustment Disorders: emotional or behavioral symptoms in response to an identifiable stressor; occurring within 3 months of stressor onset; stress-related disturbance does not meet criteria for another mental disorder or represent exacerbation of a preexisting mental disorder.

7.1 Reactive Attachment Disorder

Reactive Attachment Disorder (RAD)

Characteristics: Pattern of emotionally withdrawn behavior toward adult caregivers, minimal social and emotional responsiveness, persistent distress, limited positive emotions, irritability, sadness, fearfulness.
Causes: Severe social neglect, insufficient care, frequent caregiver changes, institutional settings with high child-to-caregiver ratio.
Impact: Impairs interpersonal relationships, developmental delays in cognition and language, potential malnutrition.
Distinction from Autism Spectrum Disorder (ASD): Reactive Attachment Disorder results from severe social neglect; ASD presents with a restricted range of interests and repetitive behaviors.
Case Study: "Grandma's Child" (Tanya)
- Age 4, only child of long-term heroin users.
- Placed in foster care after parents arrested.
- Grandparents noticed language delays, social interaction problems.
- Avoided seeking comfort or playing with grandparents and relatives.
- Fearful during interaction.
- Mild language delays, marked social interaction difficulties.
- Reversal of symptoms with consistent caring environment.
Diagnosis: Inhibited and emotionally withdrawn behavior, minimal social and emotional responsiveness to caregivers, fearfulness – results from extremely neglectful care.

7.2 Disinhibited Social Engagement Disorder

Disinhibited Social Engagement Disorder (DSED)

Characteristics:

Indiscriminate approach and interaction with unfamiliar adults
Little social inhibition toward strangers
Unattached behavior towards caregivers
Overly familiarity with strangers, even physically
May go off with complete strangers
Attention seeking in pre-school age
Verbal and physical overfamiliarity in middle childhood
Superficial and conflicted peer relationships in adolescence

Causes:

Grossly inadequate caregiving
Frequent changes in caregivers
Limited opportunities for attachment formation due to institutionalization

Behavioral Manifestations:

Hugging strangers as if known for years
Running up to unfamiliar people and wanting to be picked up
Telling strangers she will go with them
Indiscriminate approach towards strangers without hesitation or reticence

Case Study: Harlow's Behavior:

Placed in foster care due to neglect and physical abuse
Demonstrated no preference for any particular adult, approached anyone
Hugged strangers and told them she had known them for years
Tended to run off with unfamiliar adults if not prevented
Friendly and affectionate towards strangers

Implications:

Disinhibited Social Engagement Disorder is caused by significant social and physical neglect and abuse, preventing the child from forming selective and stable attachments to adult caregivers.
The diagnosis is more persistent than Reactive Attachment Disorder (RAD) and may continue into adolescence if neglectful conditions persist.

7.3 Posttraumatic Stress Disorder

Posttraumatic Stress Disorder (PTSD)

Characteristic Symptoms:

Development of certain symptoms in response to an extremely traumatic experience
Exposure to actual or threatened death, serious injury, or sexual violence
- Direct experience of threat to life or limb
- Witnessing event occurring to another person
- Learning about event affecting close family member or friend
- Repeated exposure through job (e.g., first responders)

Symptom Patterns:

Intrusion symptoms: recurrent, involuntary reexperience of traumatic event
- Distressing memories and dreams related to the event
- Dissociative reactions (flashbacks)
- Intense or prolonged psychological/physiological distress on exposure to reminders
Persistent avoidance of stimuli associated with trauma:
- Deliberately avoiding thoughts, memories, feelings about traumatic event
- Avoiding activities, objects, situations, or people that arouse uncomfortable recollections
Negative changes in cognitions and mood associated with the event:
- Inability to remember important aspects of what happened during the event
- Persistent negative beliefs about self, others, or the world
- Distorted thoughts about cause or consequences of the event
- Persistent feelings (fear, horror, anger, guilt, shame)
- Diminished interest in previously enjoyed activities
- Feeling detached or estranged from others
- Inability to experience positive emotions
Alterations in arousal and reactivity:
- Irritability, angry outbursts
- Recklessness or self-destructive behavior
- Hypervigilance
- Exaggerated startle response
- Problems concentrating
- Sleep disturbance

Duration:

Symptoms must have lasted for at least 1 month and caused clinically significant impairment in functioning
Briefer but similarly intense reactions are diagnosed as Acute Stress Disorder

Age Modifications:

Age-appropriate modifications for children under age 6 years (e.g., reenactments in play, social withdrawal instead of detachment)
If more than 6 months elapse between trauma exposure and full expression of symptoms, use "With Delayed Expression" specifier

Prevalence:

More common in the United States than most Asian, African, or Latin American countries
Higher rates among war veterans, people whose work puts them at risk for exposure to traumatic events (e.g., police, firefighters), survivors of rape, military combat, captivity, and ethnically/politically motivated internment and genocide
Women have higher rates than men
Variable course with some recovering within months while others have symptoms for decades.

The Singer

Ms. Natasha Blackman's Case

Background:

27-year-old nightclub singer
Referred to a psychologist by friend for evaluation
Experienced traumatic event: boyfriend stabbed during mugging, escaped unharmed

Symptoms and Diagnosis:

Recurrent nightmares and vivid memories of the crime
Avoidance of places/situations reminding her of the event (going out after dark)
Negative changes in cognitions and mood: withdrawal from friends, feelings of guilt and self-blame
Alterations in arousal: exaggerated startle response, trouble concentrating, sleep disturbance
Mild dissociative experiences: daydreaming, forgetting what she intended to buy

Diagnosis Discussion:

Likely case of PTSD (Post-Traumatic Stress Disorder) (DSM-5)
Symptoms began after a short latency period, but not delayed expression
If only mild and nonspecific anxiety symptoms: Adjustment Disorder with Anxiety

The Wreck

The Wreck: Case Study of Enrique Casales

Background:

40-year-old married carpenter, Mr. Casales
Motor vehicle accident 2 years ago with no head trauma or loss of consciousness
Hospitalized for neck strain and inflammation of spinal nerve to trapezius muscle in back
Diagnosis: neck strain and inflammation
Treatment: physical therapy and anti-inflammatory medication

Symptoms After the Accident:

Occasional involuntary thoughts of the accident
Trouble falling asleep, irritability, anxious mood, impaired concentration, increased appetite, weight gain
Symptoms waxed and waned over months
No avoidance behavior or loss of interest in usual activities (including sexual interest)
Continued socializing with friends
Transient anxiety when driving past accident site
Orthopedic injuries prevented return to work as a carpenter, but he continued working at "side businesses"
Marital life deteriorated due to irritability
Able to enjoy himself on camping trips

Surgery and Postsurgery Symptoms:

Decided to undergo recommended surgery for temporary disability in right shoulder and arm
Developed more dramatic symptoms:
- Unable to sleep due to terrifying dreams, unable to return to sleep for hours
- Loss of interest in sex
- Exaggerated startle response to loud noises (e.g., honking horns, slamming doors)
- Acute anxiety when a passenger in a car, nausea, outbursts of anger while driving or passing an accident site
- Unable to concentrate on side businesses
- Marital situation deteriorated due to emotional isolation from wife and planned divorce

Diagnosis:

After 6 weeks of symptoms, sought assistance from orthopedic surgeon who made a psychiatric referral
Treated with antidepressant (sertraline) and supportive psychotherapy, which promptly controlled the symptoms
Postsurgery disability resolved after 2 months, allowing full range of motion and nearly full strength
Attempts to reduce dosage of sertraline resulted in return of dreams, sleep disturbances, and high level of anxiety.

Conclusion:

In the months following the accident, Mr. Casales exhibited nonspecific anxiety symptoms that could have been diagnosed as Adjustment Disorder with Anxiety.
The full clinical picture of PTSD (with delayed expression) developed about 2 years later after undergoing surgery for injuries related to the accident.

Flashbacks

Michael Bennett's Case:

Admitted to hospital in 1975, age 23, after experiencing depression, insomnia, and flashbacks related to his Vietnam War experiences
Honorably discharged two years prior with minimal difficulties adjusting to civilian life
Wife noticed reluctance to discuss military experiences but wrote it off as normal reactions
Symptoms began around the time of Saigon's fall in 1975
Preoccupation with war news and avoidance due to distress
Flashbacks: nightmares, dissociative experiences, increased arousal, persistent negative emotions
Avoided all sources of war news
Symptoms indicate PTSD (DSM-5): intrusion symptoms, persistent negative emotions, avoidance behavior, and symptoms with delayed expression.

Michael Bennett's Diagnosis:

PTSD diagnosis based on DSM-5 criteria: intrusive memories, persistent negative emotions, avoidance behavior, and symptoms with delayed expression.
Symptoms of guilt for surviving when others did not (survivor guilt).

Impact of Trauma:

Increased risk for chronic health issues such as cardiovascular diseases, nervous system disorders, musculoskeletal disorders.
Higher mortality rate: Vietnam War veterans with PTSD are twice as likely to die over a 25-year period compared to those without PTSD.
Recent wars in Iraq and Afghanistan have produced approximately 270,000 veterans diagnosed with PTSD, half of whom receive disability benefits.
Prolonged deployments may contribute to these issues.

Memories

Mrs. Zelda Podlevner's Case Study:

Background:

Referred for psychiatric evaluation in preparation for Workmen's Compensation appeal
Problems began 6 months prior after a minor fire at her workplace
Developed abdominal pains, nausea, heart palpitations, depression, anxiety, and fear of leaving home

Fire Incident:

Triggered reliving of traumatic experience from Auschwitz concentration camp
Patient was selected to work in a gas chamber during selection process
Smell of the fire reminded her of the gas chamber

Symptoms of PTSD:

Intrusion symptoms: nightmares, distressing recollections
Avoidance of situations that remind her of trauma
Lost interest in activities, negative thoughts about self
Increased arousal: difficulty sleeping and concentrating

Current Status:

Still afraid to go back to work despite therapy
Dealing with feeling her life stopped at age 17 during the Holocaust

Discussion of "Memories":

Mrs. Podlevner's case is an example of PTSD With Delayed Expression (DSM-5)
The minor fire uncovered a deeply buried memory of a horrendous experience after many years
Symptoms of PTSD: traumatic experience involving actual or threatened death, intrusion symptoms, avoidance, negative thoughts, increased arousal.

Holocaust Survivors:

Estimated 140,000 Holocaust survivors alive in the United States (2016)
Growing old and suffering from physical and emotional problems related to traumatic experiences as well as normal aging.

Sniper

Leah's Case Study

Background:

Leah, a 6-year-old girl, referred for evaluation due to tearfulness, irritability, and difficulty concentrating in class
Two and a half months prior, Leah was pinned down by sniper fire on her school playground
One child was killed; several others injured during the 15-minute shooting incident
No personal connection to victim or perpetrator before the incident

Behavioral Changes:

Withdrew from friends, became argumentative and fearful
Irritable, moody at home
Apprehensive about new situations, fearful of being alone
Regularly asked to sleep with parents, restless sleep, crying out in her sleep
Susceptible to minor physical problems, frequent complaints of fatigue
Nearly walked in front of moving car without awareness
Engaged in "nurse games" frequently

Symptoms:

Terrified of being killed or injured again
Nightmares and dreams about the shooting incident
Afraid of loud noises, public address systems
Difficulty focusing on schoolwork, disrupted attention
Avoided playground area where shooting occurred, sniper's street
Particularly afraid during Fridays (day of shooting)
Unable to express feelings to parents, fearful and anxious

PTSD Diagnosis:

Leah experienced a traumatic event involving potential death or injury for herself and her classmates
Exhibited severe PTSD symptoms within days of the trauma: intrusive images, recurrent dreams, avoidance behaviors, negative alterations in cognition, increased arousal.

Additional Information:

Age-specific indicators of PTSD apply for children aged 6 years and younger
Leah did not experience flashbacks as adults might, but had recurrent intrusive images and recollections through games, play, dreams instead.

Nighttime Visitor

Christina's Case: A Child Victim of Sexual Abuse

Background:

Christina, 8 years old, referred to family treatment center due to disruptive behavior
Diagnosed with vaginal warts and gonorrhea
Revealed father had been sexually molesting her and sister Sara for 2 years
Father jailed, mother cited for neglect

Symptoms:

Difficulty sleeping, nightmares about father
Fearful of divulging secrets to others
Irritable and aggressive at home
Avoidance of friends, fear of rejection
Clinging to therapist
Traumatic play in therapy sessions

Stressor Requirement:

Repeated sexual abuse by father meets stressor requirement for PTSD

Symptoms of PTSD:

Intrusion symptoms: nightmares about trauma
Avoidance: avoiding thinking about the trauma, distraction with TV
Increased arousal: difficulty falling asleep, irritability and aggression
Negative emotions: depressed mood, guilt, fear of rejection

Possible Diagnosis:

PTSD due to sexual abuse by father
Depressive Disorder possible but not diagnosed based on given symptoms.

7.4 Acute Stress Disorder

Acute Stress Disorder (ASD)

Similar manifestations to PTSD but duration lasts from 3 days to 1 month after exposure to trauma
Characteristics of stressor: exposure to actual or threatened death, serious injury, or sexual violence (DSM-5, p. 280)
Symptoms:
- Any 9 out of 14 symptoms regardless of category
- Fewer than 20% of people exposed to traumatic events develop ASD
- Higher prevalence among women
- May progress to PTSD (approximately half of PTSD cases had Acute Stress Disorder immediately after the stressor)
Symptoms of Acute Stress Disorder:
- Distressing memories and recurrent nightmares
- Negative mood changes, such as no joy about past events or difficulty concentrating on work
- Dissociative symptoms, like being in a daze or unaware of surroundings
- Avoidance behavior, refusal to discuss the traumatic event
- Symptoms of increased arousal, such as sleep disturbances and exaggerated startle response (DSM-5, p. 281)
Example: Vicky Lawson's case - a woman with a 28% burn injury and her experience after the trauma
- Fearful and anxious
- Nightmares and recurring distressing memories
- Dissociative symptoms (in a daze, unable to remember husband's death)
- Avoidance behavior (refuses to talk about what happened)
- Symptoms of increased arousal (sleep disturbances, hypervigilance, and exaggerated startle response)
Diagnosis: Acute Stress Disorder (DSM-5, p. 280)

Acute Stress Disorder vs. PTSD

ASD requires symptoms to persist for at least 3 days but less than 1 month
Transient acute symptoms are common following traumatic events and most people recover within a few days or weeks
DSM-5 uses the diagnosis of Acute Stress Disorder when PTSD-like symptoms interfere with social or occupational functioning (DSM-5, p. 280)

Example: Karen Davidoff's case - eyewitness to a murderer's execution
- Detached feeling and in a daze after the event
- Unable to concentrate on work, dissatisfied with it
- Difficulty sleeping, nightmares of the execution
- Reexperiences trauma through intrusive recollections, flashbacks (vivid "snapshot" images), negative mood state, and dissociative symptoms.

Diagnosis: PTSD (not met criteria for ASD as symptoms persisted beyond a month) (DSM-5, p. 273)

7.5 Adjustment Disorders

Adjustment Disorders

Definition: Distressing emotional or behavioral reaction to a stressful life event that causes significant distress or interferes with social or occupational functioning.

Types of Stressors:

Single event (e.g., breakup of a relationship)
Series of events (e.g., loss of job and need to move)
Ongoing situation (e.g., illness, poverty)

Diagnosis:

Adjustment Disorder if stressor does not meet criteria for another mental disorder or normal bereavement
Adjustment Disorders can manifest in various ways:
- With Depressed Mood
- With Anxiety
- With Mixed Anxiety and Depressed Mood
- With Disturbance of Conduct
- With Mixed Disturbance of Emotions and Conduct
Duration: Begins within 3 months of onset of stressor and lasts no longer than 6 months after the stressor or its consequences have ceased.

Case Examples:

Happy Ending (Esther):
- Reacted with bouts of sadness and crying after boyfriend wanted to stop seeing her
- No other signs of depressive syndrome
- Diagnosis: Adjustment Disorder, With Depressed Mood
Abducted (Kaitlyn):
- Demonstrated various symptoms of anxiety since being abducted by father 5 months previously
- No evidence of other Anxiety Disorders or Generalized Anxiety Disorder
- Diagnosis: Adjustment Disorder, With Anxiety.

No One Hits the Baby

Carol's Case Study:

Four-year-old girl referred for evaluation due to behavioral issues at school
Problems began with birth of sister three months ago
Teacher noticed change in behavior: pushing other children, hitting classmate, causing injury
Family evaluation revealed father's physical abuse towards Carol and her own feelings of neglect
Father's increased drinking and irritability, arguments between parents over infant care
Mother had little time for Carol due to infant's colic
Carol experienced difficulty sleeping, repeated tantrums, demands for attention
Father responded with physical violence, hitting her with a belt
Diagnosis: Adjustment Disorder With Mixed Disturbance of Emotions and Conduct (DSM-5)

Consequences of Child Abuse:

Children who are physically or sexually abused at risk for various disorders
Major Depressive Disorder, Separation Anxiety Disorder, Oppositional Defiant Disorder, Conduct Disorder, Suicidal Behavior, Psychoactive Substance Use in adolescents (long-term consequences: Borderline Personality Disorder, Dissociative Identity Disorder)
Abused children may abuse their own children
The level of abuse identified in this case is not as severe as some other cases where multigenerational abuse has been identified.

CHAPTER 8 Dissociative Disorders

Dissociative Disorders

Dissociation: mental process disrupting connection between conscious awareness and aspects of self (memory, identity, perception)
On a continuum of severity
Mild dissociation: daydreaming, getting lost in a book, altered states from drug use
Problematic dissociation: 3 specific DSM-5 disorders present

Characteristics of Dissociative Disorders

Dissociative Identity Disorder (DID)

Disruption of identity
Two or more distinct personality states
Recurrent gaps in recall of everyday events

Dissociative Amnesia

Inability to recall important autobiographical information, usually traumatic or stressful

Depersonalization/Derealization Disorder

Persistent or recurrent experiences of:
- Depersonalization (unreality or detachment from self)
- Derealization (unreality or detachment from surroundings)

Additional Considerations

Dissociative symptoms not necessarily indicative of a Dissociative Disorder
Can occur in other disorders: Panic Attack, Posttraumatic Stress Disorder
May not indicate any disorder at all.

8.1 Dissociative Identity Disorder

Dissociative Identity Disorder (DID)

Characteristics:

Multiple distinct personality states, or "alters"
Each alter has unique traits, history, thought processes, and ways of relating to surroundings
Some alters may be of different genders with distinct names and mannerisms
Stress or trauma triggers switch between alters
Symptoms include amnesia, time loss, unfamiliar people claiming to know the person, and missing items

Causes:

Severe childhood trauma, often involving extreme physical, sexual, or emotional abuse
Dissociative coping mechanism for dealing with unassimilable trauma

Controversy:

Some argue it is underdiagnosed due to the shifting nature of symptoms
Others claim diagnoses are based on suggestion from therapists or famous cases like "The Three Faces of Eve" or "Sybil"

Case Study: Mary Kendall (Mary Quite Contrary)

35-year-old social worker referred for treatment of reflex sympathetic dystrophy
Highly hypnotizable and used self-hypnosis to control pain
Competent at work but had a lackluster personal life
Strange occurrences: unexplained car gas tank drops, memory gaps, nighttime driving without recall
Psychiatric evaluation revealed dissociative disorder and six additional personality states
Personality states organized along dependent-aggressive continuum, tension between them
Memories of physical/sexual abuse by father and others, guilt about not protecting siblings
Four years of psychotherapy resulted in partial integration of personality states.

8.2 Dissociative Amnesia

Dissociative Amnesia:

Definition: Unconscious blocking out of important personal information, often related to a stressful or traumatic event like child abuse or combat.

Types:

Situation-specific: Memory loss for particular incidents
Global: Complete gap in memory lasting months to years
Localized amnesia: Failure to recall events during circumscribed period of time
- Selective: Remembering some parts but not others
- Generalized: Complete loss of memory for life history and personal identity

Characteristics:

Memories still exist but deeply buried
Can resurface on their own or after being triggered
Some episodes resolve rapidly, while others persist for long periods
High prevalence of suicidal and self-destructive behaviors

Statistics: 1.8% 12-month prevalence among adults in the U.S., more common in females than males, can occur at any age group.

The Sailor

The Sailor's Case

Background:

18-year-old male named Joshua brought to hospital by police
Appeared exhausted, sun exposure
Incorrectly identified date as September 25 instead of October 1
Difficulty focusing on specific questions
Recalled sailing with friends off Florida coast on September 25
Unable to recall events after September 25 or what happened to his companions
Initially uncertain of his whereabouts

Initial Examination:

No evidence of head injury or dehydration
Permitted to sleep for 6 hours, became more attentive upon awakening
Still unable to recall events after September 25 but aware of hospital environment
Able to remember personal details like student status, friends, family, and denial of psychiatric history

Additional Interview:

Conducted under influence of amobarbital (truth serum)
Revealed he and companions were inexperienced sailors
Lost control during storm, secured only with a lifeline
Consumed food supplies for 3 days before being rescued by Coast Guard
Never saw sailing companions again after they were washed overboard

Diagnosis:

Inability to remember specific period of time indicates dissociative amnesia (DSM-5, p. 298)
Rule out external causes: no evidence of head trauma, stroke, medical conditions, drug or alcohol use, or physical disturbance in brain functioning.
Memory loss caused by psychological stress confirmed during amobarbital interview.

Burt Tate

Patient Background:

42-year-old white male brought to emergency room by police
Known as "Burt Tate" but no identification found
Had been working as a short-order cook at diner for several weeks
No charges against him, kept overnight for observation

Identity Crisis:

Police background check revealed patient was a missing person, Gene Saunders
Mrs. Saunders confirmed identity and provided history
Previously a middle-level manager at manufacturing company
Struggling at work, passed over for promotion, criticized by supervisor
Could not meet production goals, staff left the company
Withdrawn and critical of wife and children
Violent argument with 18-year-old son preceded disappearance

Memory Loss:

Unable to recall details of past life
No evidence of alcohol or drug abuse
Physical examination revealed no abnormalities
Knew town name, current date but anxious and confused upon meeting wife

Diagnosis:

Dissociative Amnesia with Dissociative Fugue (DSM-5)
Previously separate disorder in DSM-IV, now folded into Dissociative Amnesia
Onset linked to severe stressors: job promotion issues, work stress, family conflict

Rarity:

Quite rare in real life with a prevalence of less than 0.2%
Commonly used as plot device in books, TV shows, and movies.

8.3 Depersonalization/Derealization Disorder

Depersonalization/Derealization Disorder

Characteristics:

Lack of integration of one or more components of perception
Persistent or recurrent episodes of depersonalization, derealization, or both
Depersonalization: feeling unreal or detached from self, thoughts, feelings, sensations, body, or actions
Derealization: surroundings feel unreal, others appear dreamlike, foggy, lifeless, visually distorted
Altered subjective experience of reality, but not a form of psychosis
Can last from minutes to years

Statistics:

Approximately 50% of the general population has had an episode
Occurs in many mental and physical disorders, including Panic Disorder, PTSD, BPD, seizure disorders
Persistent or recurrent depersonalization/derealization: occurs in about 2% of the population

Case Study: Edward Alvarez

College student experiencing increasing frequency and duration of episodes
Sense of deadness in body, uncertain balance, lack of easy control over thoughts and actions
Feeling outside himself, uncertain of identity
Foggy thoughts reminiscent of anesthetic experiences
Anxiety about return of symptoms, fear of accidents while driving
Distressing symptoms led to decreased affection from girlfriend
No significant impairment in concentration or daily functioning
Slept well and maintained unimpaired college grades.

Diagnosis:

Depersonalization/Derealization Disorder (DSM-5, p. 302)
No evidence of derealization symptoms in Edward's case
Not indicative of psychotic disorder despite feelings of going insane or fear of institutionalization.

CHAPTER 9 Somatic Symptom and Related Disorders

Somatic Symptom and Related Disorders

DSM-5 Diagnoses:

Somatic Symptom Disorder: Distressing or impairing somatic symptoms
Illness Anxiety Disorder: Preoccupation with having or acquiring a serious illness in the absence of prominent somatic symptoms, high anxiety about health
Conversion Disorder (Functional Neurological Symptom Disorder): Symptoms of altered motor or sensory function not compatible with known neurological conditions
Psychological Factors Affecting Other Medical Conditions: Psychological or behavioral factors negatively influencing a medical condition
Factitious Disorder: Feigning a medical illness or disorder in the absence of obvious external incentives

Key Characteristics:

Somatic Symptom Disorder: Distressing or significant disruption of daily life, excessive thoughts, feelings, or behaviors related to somatic symptoms/health concerns
Illness Anxiety Disorder: Preoccupation with having or acquiring a serious illness, high anxiety about health, excessive health-related behaviors or avoidance
Conversion Disorder: Symptoms of altered motor or sensory function incompatible with known neurological conditions
Psychological Factors Affecting Other Medical Conditions: Psychological or behavioral factors adversely affecting a medical condition, additional health risks, influencing underlying pathophysiology
Factitious Disorder: Falsification of physical or psychological signs/symptoms, induction of injury or disease, treated by mental health professional rather than non-psychiatric medical clinic

Diagnostic Shift in DSM-5:

Diagnosis based on presence of somatic symptoms and level of distress/impairment, rather than unexplained medical symptoms
Patients often rejected psychological origin of physical symptoms, preferring medical treatment
Limited ability of mental health clinician to determine medically unexplained symptoms

9.1 Somatic Symptom Disorder

Somatic Symptom Disorder

Definition:

Distress or disruption of life due to physical symptoms
Multiple current somatic symptoms lasting at least 6 months
Can be specific or nonspecific, sometimes only one severe symptom (e.g., pain)
Normal bodily sensations may also be a concern
May be accompanied by another medical condition
Excessive worry and focus on health concerns

Characteristics:

Individuals believe they have physical ailments despite negative test results
Preoccupation with symptoms and their consequences
Difficult to reassure
Central role in the individual's life
Anxiety about health, sensitivity to drug effects

Specifiers:

With Predominant Pain (for chronic pain presentations)
Persistent (for severe and chronic cases)

Statistics:

Approximately 5%-7% prevalence in adult population
More common in females than males
Can begin at any age but often starts in early adulthood

Case Study: Gloria Jackson

Divorced, unemployed secretary
Hospitalized for unusual physical complaints
Contorted position with jerking movements
Bedridden for extended periods, experiencing "seizures" several times a week
Worry about serious disease, no definitive diagnosis despite numerous doctor visits
History of abdominal pain since age 17, multiple hospitalizations for various symptoms (hiatal hernia, neurological, hypertensive, renal issues)
Preoccupation with symptoms and fear of disease dominates conversations and thoughts.

No Parking

Vanessa Abernathy's Case:

Background: Vanessa Abernathy, a 36-year-old traffic enforcement agent, was referred for psychiatric examination by her lawyer after an incident 10 months prior.
Incident Details: She wrote a ticket and placed it on an illegally parked car; a man swore at and attacked her, knocking her down with enough force to fracture her jaw. She was hospitalized and diagnosed with a hairline fracture, but recovered after a month.
Physical Symptoms: Post-recovery, she experienced severe pain and muscle tension in her neck and back, becoming virtually immobilized. She spent most of her time sitting or lying down.
Behavioral Patterns: She talked about her pain constantly to family and friends, who grew tired of it. She also hired a lawyer to challenge Workers' Compensation Board's decision to cut off payments and threatened her employer for not returning to work.
Diagnosis: The psychiatrist diagnosed Ms. Abernathy with Somatic Symptom Disorder, With Predominant Pain (DSM-5, p. 311).
Malingering vs. Somatic Symptom Disorder: The question was raised if her pain symptoms were being fabricated or exaggerated to avoid work and receive financial compensation. However, her genuine suffering and desire to return to work made this unlikely.

9.2 Illness Anxiety Disorder

Illness Anxiety Disorder (IAD)

Individuals excessively focus on physical health and fear of developing serious diseases
Preoccupation impairs social and occupational functioning or causes significant distress
Symptoms may include normal physiological sensations, benign dysfunctions, or self-examination
Excessive anxiety about medical conditions or risk factors disproportionate to severity

Characteristics of Individuals with IAD:

Seek regular reassurance from family, friends, and healthcare providers
Relief is short-lived before worrying about symptoms again
May engage in repeated self-examination and diagnostic tests
Maladaptive avoidance of situations or activities due to fear of jeopardizing health
Easily alarmed by illness news or stories

The Radiologist Case Study:

Mr. Davies: 38-year-old radiologist with a history of excessive medical examinations and anxiety about potential diseases
Diagnosed with benign heart murmur as a teenager, which led to longstanding health concerns
Preoccupied with various symptoms, including abdominal sensations, fearing they indicate colon cancer or other serious conditions
Engages in self-diagnostic behaviors such as X-ray studies and stool tests
Spends significant time researching illnesses online
Strain on marriage due to time spent on health concerns

Diagnosis:

Mr. Davies exhibits symptoms of Illness Anxiety Disorder (IAD) rather than Somatic Symptom Disorder, as his focus is on the implications of symptoms rather than the discomfort itself.

9.3 Conversion Disorder

Conversion Disorder (Functional Neurological Symptom Disorder)

Symptoms:

Altered voluntary motor or sensory function: paralysis, weakness, abnormal movements (tremor, gait abnormalities), altered skin sensation, vision, hearing
Seizure-like episodes with impaired consciousness
Unresponsiveness resembling fainting or coma
Reduced speech volume, inability to speak clearly, double vision

Characteristics:

Symptoms not explained by neurological examination and diagnostic tests
Lack of conscious feigning or external incentives for symptoms
Inconsistency between complaint and findings
Clear evidence of incompatibility with neurological disease (e.g., positive physical signs under different testing methods)

Demographics:

Rare in general population, but more common among neurology patients (approximately 5%)
More common in women than men (two to three times)
Higher prevalence in developing countries and lower socioeconomic status

Case Study: Pari Chatterjee
Symptoms:

Fits with sudden onset, lasting 30-60 minutes
Unresponsiveness and rigid body during fits
Bizarre movements of extremities
Closed eyes, jaw clenched, frothing at the mouth
Abusive language or crying

Findings:

Normal physical examination (mild anemia only)
Negative neurological tests: skull X-ray, routine electroencephalogram (EEG), ambulatory EEG study
Absence of seizure activity during fits

Treatment and Discussion:

Family sessions to address misunderstandings about the nature of symptoms
Encouraging husband's active role in handling conflicts with in-laws
No more fits reported after 2 months of therapy.

Diagnosis:

Conversion Disorder, With Attacks or Seizures (DSM-5, p. 318)
Symptoms not explained by neurological causes based on normal test results and absence of seizure activity during fits.

9.4 Psychological Factors Affecting Other Medical Conditions

Psychological Factors Affecting Other Medical Conditions (DSM-5)

Condition Definition:

Diagnosed when psychological or behavioral factors adversely impact existing medical conditions, such as diabetes mellitus or heart disease, or symptoms like pain
Influence can be demonstrated through various means:
- Close temporal association between psychological factors and development/exacerbation of medical condition
- Interference with treatment, e.g., denial of significance or severity leading to poor adherence
- Established health risks, such as chronic occupational stress increasing risk for hypertension

Examples:

Asthma exacerbated by anxiety
Denial of need for treatment in a patient with cancer
Manipulation of insulin by an individual with diabetes to lose weight

Types of Psychological Factors:

Symptoms of depression or anxiety
Stressful life events
Personality traits
Coping styles

Effects:

Acute: refusal to seek care during an acute myocardial infarction
Chronic: stress leading to overeating and obesity

Case Study: Eileen Cameron

42-year-old trial lawyer with duodenal ulcer disease
Increased workload and stress at work and home
Denies significant mental disorder history
Manages stress by getting things done without thinking about the rest
Psychologist suggests exploring alternative coping mechanisms to reduce risk of another ulcer

Understanding Peptic Ulcers:

Multifactorial in etiology, involving biological, social, and psychological factors
Associated with H. pylori infection and NSAID use, but not all people with these conditions develop peptic ulcers
Incidence increased with disasters, job stress, family conflict, depression, and hostility.

9.5 Factitious Disorder

Factitious Disorder

Definition:

Characterized by falsification of medical or psychological signs and symptoms in self or others
Individuals misrepresent, simulate, or cause signs or symptoms of illness or injury

Types:

Factitious Disorder Imposed on Self: individual presents him/herself as ill, impaired, or injured
- Desire for sympathy and attention
Factitious Disorder Imposed on Another (formerly Factitious Disorder by Proxy)
- Individual produces or fabricates symptoms in a dependent person
- Perpetrator takes victim for medical care while denying knowledge of problem

Symptoms:

Misrepresentation, simulation, or manipulation of illness or injury
False reporting of symptoms (e.g., seizures, dizziness)
Alteration of laboratory tests (e.g., adding blood to urine)
Falsification of medical records
Self-inflicted injuries or induction of illness in others

Diagnosis:

Demonstrated misrepresentation, simulation, or causing signs/symptoms of illness
No obvious external rewards for appearing sick (e.g., insurance money, disability)
Not considered a mental disorder in DSM-5 but can be recorded as focus of clinical attention (Malingering)

Statistics:

Difficult to obtain accurate statistics due to dishonesty and multiple treatments at different facilities
Estimated that about 1% of hospitalized individuals may have Factitious Disorder.

Fraulein von Willebrand

Fraulein von Willebrand (Factitious Disorder Imposed on Self)

Patient: Jane Powell, 29-year-old female laboratory technician
Presented to emergency room with blood in urine
Background: Being treated for Systemic Lupus Erythematosus (SLE) and von Willebrand's disease
Suspicious Behavior: Refused to discuss recent hospitalization, had anticoagulant medication cache
Diagnosis: Factitious Disorder Imposed on Self (DSM-5, p. 324)

Take Me Seriously (Factitious Disorder)

Patient: Clara Beaumont, 56-year-old unmarried female
Seeked therapy to refute Factitious Disorder diagnosis from medical providers
History: Long history of various medical problems, including osteonecrosis, COPD, and cancer
Behavior: Dramatic and exaggerated representations of medical conditions, selective record access
Diagnosis: Factitious Disorder (DSM-5, p. 324)
Similarities: Both patients presented with fabricated or exaggerated medical histories

Medical Miscreant (Factitious Disorder Imposed on Another)

Patient: Chris, an 11-year-old boy
Mother falsely claimed various illnesses and underwent unnecessary procedures
Mother's Behavior: Manipulation of medical system for sympathy and attention
Risks: Permanent disability or death if left unchecked
Diagnosis: Factitious Disorder Imposed on Another (DSM-5, p. 325)

CHAPTER 10 Feeding and Eating Disorders

Feeding and Eating Disorders (DSM-5)

Overview:

Eating disturbances may indicate various mental disorders, but not necessarily Feeding and Eating Disorders
DSM-5 chapter on "Feeding and Eating Disorders": persistent disturbances in eating behavior impairing physical health or psychosocial functioning

Types of Feeding and Eating Disorders:

Pica: Eating nonnutritive, nonfood substances
Rumination Disorder: Regurgitation of food before absorption
Avoidant/Restrictive Food Intake Disorder (ARFID): Failure to meet nutritional and energy needs, intense fear of gaining weight or becoming fat
Anorexia Nervosa: Restriction of energy intake leading to significantly low body weight, disturbed body image
Bulimia Nervosa: Binge eating followed by purging, self-evaluation influenced by body shape and weight
Binge-Eating Disorder: Binge eating without purging, no inappropriate compensatory behaviors

Diagnostic Considerations:

Mutually exclusive diagnoses for a given episode (only one diagnosis can be given at a time)
Different longitudinal courses, outcomes, and treatment needs.

10.1 Pica

Pica

Definition:

Persistent eating of nonnutritive, nonfood substances (DSM-5, p. 330)
Examples: paper, soap, cloth, hair, etc.
Does not apply if infant accidentally ingests something
Can lead to medical emergencies and nutritional deficiencies

Characteristics:

May be associated with another mental disorder or pregnancy cravings
Serious disorder for potential risks

Case Study: "Omnivorous George"

5-year-old admitted for nutritional anemia due to ingestion of nonnutritive substances (paint, plaster, etc.)
History of numerous hospitalizations since age 19 months (lighter fluid)
Parents described as immature and dependent, low socioeconomic status
Mother ate dirt during pregnancy
Father periodically abused drugs and alcohol

Additional Information:

May be developmentally appropriate for infants, but persistent behavior warrants diagnosis of Pica (DSM-5, p. 329)
In some cultural settings, eating nonnutritive substances may be sanctioned practice, but not in all cases.

10.2 Rumination Disorder

Rumination Disorder

Characteristics:

Repeated regurgitation of food after feeding or eating
Regurgitated food may be partially digested and re-chewed, re-swallowed, or spit out
Not caused by gastrointestinal conditions like gastroesophageal reflux or pyloric stenosis

Associated Conditions:

Anorexia Nervosa: individuals may regurgitate and spit out food to control weight gain
Bulimia Nervosa: individuals may regurgitate food as a means of getting rid of ingested calories

Diagnosis:

If rumination is a symptom of another mental disorder, Rumination Disorder is not diagnosed
If rumination requires special clinical attention, a diagnosis can be made even if associated with another mental disorder

Occurrence:

Can occur in infancy, childhood, adolescence, or adulthood
Most common among infants between ages 3 and 12 months

Consequences:

Can lead to malnutrition, growth delay, developmental and learning problems, and even be fatal in infants

Case Study: "Baby Olivia"

6-month-old infant with failure to gain weight and regurgitation after every feeding
Parents making a marginal marital adjustment and often talking about separation or divorce
Lack of evidence of inappropriate social relatedness rules out Reactive Attachment Disorder
Regurgitation is the cause of weight loss, indicating Rumination Disorder

10.3 Avoidant/Restrictive Food Intake Disorder

Avoidant/Restrictive Food Intake Disorder (ARFID)

Characteristics:

Persistent failure to meet appropriate nutritional and/or energy needs
Lack of interest in eating or food
Food avoidance based on extreme sensitivity to sensory characteristics of food
Concern about negative consequences of eating, such as choking or vomiting
Results in weight loss or failure to gain weight (in children)
Nutritional deficiency
Need for food supplements
Impairment in psychosocial functioning

Diagnosis:

DSM-5 diagnosis: 334.10
Occurs most frequently in infancy and early childhood (failure to thrive)
Expanded to include food avoidance or restriction at any age
Not related to Anorexia Nervosa, Bulimia Nervosa, or a concurrent medical condition
May occur with other mental disorders: Anxiety Disorders, Autism Spectrum Disorder, Obsessive-Compulsive Disorder, Attention-Deficit/Hyperactivity Disorder
Diagnosed in addition to the other disorder if food avoidance is severe or requires special clinical attention
Not warranted if gastrointestinal problems cause food avoidance (gastroesophageal reflux)

Case Study: Roberto

6-month-old admitted for failure to gain weight, below the 15th percentile
Colic symptoms: recurrent episodes of prolonged crying and irritability
Poor synchrony between mother and baby during feeding
Disinterested in feeding, distressing experience for both mother and child
No specific medical condition accounting for difficulties

Maternal Depression and Marital Problems:

Contributed to mother's difficulties in feeding Roberto
Treatment of depression and underlying marital problems facilitated the mother's adjustment
Gradual diminishment of Roberto's feeding difficulties
Within a few weeks, he gained several pounds.

Picky Eater

Nicole's Case:

Background:

14-year-old ninth grader brought to treatment due to concerns about her ability to socialize with peers and approach new situations
Prefers being alone, avoids eating in public and trying new foods
Has limited preferred foods: white bread, crepes, grilled cheese, pizza, yogurt drinks, milk, juice
Doesn't eat fruits, vegetables, meat or chicken
Worries about abdominal pain after trying new foods
Embarrassed by eating the same thing every day at school
Below normal curve for weight on growth chart (73 pounds), significantly underweight for height (5')
Has not started menstruating
Tall and lanky, no concerns about appearance
Early feeding concerns: refused formula as a baby, only ate slightly larger variety of foods at young age

Diagnosis:

ARFID (Avoidant Restrictive Food Intake Disorder): Significant weight loss or failure to gain expected weight due to food restriction and sensory characteristics/aversive consequences of eating.

Treatment:

Evidence-based treatments for Eating and Anxiety Disorders
Combination of medication (SSRI) and CBT for moderate to severe anxiety
Goals: increase ability to eat in different settings, expand food variety, implement parent management strategies for increasing food intake.

Additional Considerations:

Anorexia Nervosa: Intense fear of gaining weight or becoming fat, not applicable as Nicole doesn't have concerns about her appearance
Social Anxiety Disorder: Embarrassment in situations beyond eating behavior, some social anxiety present but not captured by embarrassment over eating.

10.4 Anorexia Nervosa

Anorexia Nervosa

Characteristics:

Persistent refusal to maintain body weight
Fears of gaining weight or becoming fat
Disturbance in self-perceived weight or shape
Weight significantly below normal for age, sex, developmental stage, and physical health
Loss of significant amount of weight or failure to make expected gains through dieting, fasting, excessive exercise, or a combination of these

Subtypes:

Restricting Type: No binge eating or purging
Binge-Eating/Purging Type: Engages in binge eating and self-induced vomiting or misuse of laxatives, diuretics, or enemas

Symptoms:

Fear of gaining weight or becoming fat often persists or increases as weight is lost
Denial of fear of becoming fat but engaging in behaviors to interfere with weight maintenance
Focus on specific body parts that are perceived as "fat"
Weight loss perceived as a sign of self-control, weight gain seen as failure
Lack of recognition of medical seriousness of condition

Prevalence:

12-month prevalence in young females: approximately 0.4%
10 times more common in females than males
Usually begins during adolescence or young adulthood
Extremely serious and life-threatening condition due to malnutrition impacting major organ systems

Treatment:

Expert treatment is necessary for a good outcome
Diagnosis of Obsessive-Compulsive Disorder if obsessions and compulsions are not related to food, body shape, or weight.

Case Study: Peggy Sims

20-year-old woman with a weight of only 67 pounds
Began losing weight 4 years earlier, initially for weight loss and later through dieting and excessive exercise
Lost over 80% of her normal weight, leading to complications like peptic ulcer disease and amenorrhea
Recovered with inpatient treatment, including psychotherapy and weight gain strategies.

Close to the Bone

Anorexia Nervosa Case Study: Ms. Duval's Story

Background:

23-year-old woman from Arkansas
College student who used extreme measures to lose weight, including laxatives and self-induced vomiting
Described as underweight, weighing around 90 pounds at her lowest point
Suffered from distorted body image, fear of gaining weight, and binge eating followed by purging

Symptoms:

Used laxatives for two years, eventually increasing dosage to 250-300 pills at a time
Experienced severe dehydration, gastrointestinal issues, and ulcer
Forced vomiting after eating small amounts of food
Maintained extremely low weight through rigorous exercise routine and restrictive diet
Fearful of gaining even a few pounds, avoiding water intake and certain foods

Diagnosis:

Anorexia Nervosa, Binge Eating/Purging Type (DSM-5)

History:

Started using laxatives in college to lose weight
Gradually increased dosage over time
Developed extreme fear of gaining weight and distorted body image
Lost nearly 50 pounds in a few months, reaching a low point of 90 pounds
Experienced hair loss, loose teeth, and other physical manifestations of malnutrition
Recognized her condition but continued to struggle with eating disorders

Treatment:

Participated in research studies on the research ward
Received psychoanalytically-oriented psychotherapy twice a week for approximately 6 months
Attended nutritionist sessions to learn about healthy diets and maintain normal weight
Continued to experience intermittent binge eating, vomiting, and diuretic abuse but with reduced frequency and severity

Significance:

Anorexia Nervosa is a long-standing disorder with irrational fear of becoming obese despite being underweight
Ms. Duval's case illustrates the binge eating/purging type of anorexia nervosa, which involves periodic binges followed by compensatory purging behaviors to lose weight
Anorexia Nervosa can lead to various complications such as malnutrition, osteoporosis, cardiac issues, and mental health disorders if left untreated.

Thin Tim

Emergency Evaluation: "Thin Tim"

Referred by pediatrician due to unexplained weight loss over past year
Concerned about weight, weighs himself daily, feels too fat despite being underweight
- Loses 10 pounds in the past year
- Parents remove scales from house, Tim keeps calorie record instead
Obsessed with cleanliness and neatness
- Refuses to visit friends due to perceived "dirtiness"
- Agitated when touched by others
- Checks that things are done correctly
Wakes up early before school to prepare (up to 2 hours)
- Recently woke up at 1:30 AM

Diagnosis:

Anorexia Nervosa, Restricting Type (DSM-5, p. 338)
- Fear of becoming fat and feeling fat despite being underweight
- Exclusive weight loss through dieting, no binge eating or purging behavior
Secondary diagnosis: Obsessive-Compulsive Disorder (OCD) (DSM-5, p. 237)
- Preoccupation with dirtiness causes distress
- Thoughts intrude into consciousness beyond control
- Lengthy "getting ready" routines performed in response to these thoughts.

10.5 Bulimia Nervosa

Bulimia Nervosa

Characteristic Features:

Recurrent episodes of binge eating
Recurrent inappropriate behaviors to compensate for binge eating (purging or fasting)
Self-evaluation that overemphasizes body shape and weight

Binge Eating:

Defined as eating a larger amount than most individuals under similar circumstances
Associated with loss of control, feeling dissociated during the episode
Triggered by psychosocial stress, depression, or anxiety
May result in serious medical complications (fluid and electrolyte imbalances, tears/rupture in esophagus or stomach, cardiac arrhythmias)

Compensatory Behaviors:

Purging: self-induced vomiting (most common), diuretic or laxative misuse, enema use
Excessive exercise or fasting instead of purging

Diagnosis:

Bulimia Nervosa if binge eating and compensatory behaviors occur regularly
Binge Eating Disorder if no regular compensation for overeating

Ms. Thurmond's Case:

Sold first screenplay, experienced "postpartum" letdown
Attended friend's daughter's wedding with emotional trigger
Experienced binge episode lasting several hours
Consumed a mix of savory and sweet foods
Ate in secrecy due to shame
Relapse into binge eating for 6 months, worsening depression and isolation
Seeked therapy and OA support but continued relapsing
Prescribed antidepressant medication and structured food plan, eventually discontinuing both while maintaining control over eating behavior.

The Fat Man

Case Study: Gregory James' Eating Disorder

Background:

43-year-old theatre manager
Lost 58 pounds over 5 months (250 to 192 lbs)
Terrified of becoming "fat" despite losing weight

Dieting and Vomiting:

Strict diet: omelet, bran, coffee, salad, shrimp or chicken for meals
Induced vomiting after meals
Obsessed with food and weight
Frequent binges (3 hamburgers, 2 orders of French fries, pint of ice cream, 2 packages of Oreos)

Preoccupation with Thinness:

Revised weight goal: 190 lbs then 185 lbs
Exercises daily and with weights
Believes women look at him differently since losing weight

Diagnosis:

Anorexia Nervosa not applicable due to normal weight
Bulimia Nervosa (recurrent binges, inappropriate compensatory behavior)

Compensatory Behavior:

Vomiting
Less common methods: laxatives, diuretics, fasting, excessive exercise

Unusual Aspects:

Male gender
Onset of disorder later in life (adolescence or early adult life is usual)

10.6 Binge-Eating Disorder

Binge-Eating Disorder

Characteristics:

Recurrent episodes of binge eating
No inappropriate compensatory behaviors (unlike Bulimia Nervosa)
Eating binges involve consuming larger amounts than most people would over the same time period and under similar circumstances
Associated with a sense of lack of control over eating
Eating binges often characterized by:
- Eating much more rapidly than normal
- Eating until uncomfortably full
- Eating large amounts when not hungry
- Eating alone due to embarrassment
- Feeling disgusted, depressed, or guilty afterward

Prevalence:

12-month prevalence in U.S. adult population:
- 1.6% in females
- 0.8% in males
Ratio of women to men is more equal than Bulimia Nervosa
Found in as many women from racial and ethnic groups as in white women
Occurs in children, adolescents, and college-age people

Impact:

Associated with poor social adjustment
Impaired health-related quality of life
Increased medical morbidity and mortality
Increased health care utilization

Case Study: Andrea Simpson

Ms. Simpson, 35, weighed 230 pounds when seeking help for eating and weight problems
Suffered from uncontrollable binge eating, gaining over 50 pounds in 6 months
Memories of being bullied in childhood about her weight and arguments with mother about excessive eating
Began binge eating in college, alternating between dieting and overeating periods
Preoccupied with food and urges to eat during dieting periods
Struggled with weight fluctuations throughout life
Tried various diets, medications, and therapies without success
Found a combination of Overeaters Anonymous (OA) and psychotherapy helpful in losing 60 pounds over 5 years
Continues to attend OA meetings to manage her eating problem

CHAPTER 11 Elimination Disorders

Elimination Disorders

Developmental Milestones:

Toddler phase (1-3 years): interest in mastering elimination of body waste
By age 4: achieved bowel and bladder continence
- Nighttime bowel control
- Daytime bowel control
- Daytime bladder control
- Nighttime bladder control

Disorders:

Enuresis (wetting): Repeated voiding of urine into inappropriate places
- Minimum age requirement: 5 years or equivalent developmental level
Encopresis (soiling): Repeated passage of feces into inappropriate places
- Minimum age requirement: 4 years or equivalent developmental level

Key Characteristics:

Enuresis:
- Urine in bed or clothes
- Chronological age of at least 5 years or equivalent developmental level
Encopresis:
- Passage of feces into inappropriate places
- Chronological age of at least 4 years or equivalent developmental level

Other Features:

Disorders may be voluntary or involuntary
Can occur separately, but co-occurrence is possible

11.1 Enuresis

Enuresis

Definition:

Repeated voiding of urine during day or night into bed or clothes
Not under person's control for most cases
Diagnosis requires minimum frequency of twice a week for 3 months
Clinically significant distress or impairment in social, academic functioning
Age at which continence is expected: chronological or mental age of 5 years
Cannot be due to substance effects or general medical conditions

Types:

Nocturnal Only (Monosymptomatic): Urinary incontinence during nighttime sleep
Diurnal Only: Urinary voiding only during waking hours
- With "urge incontinence"
- Or "voiding postponement"
Nocturnal and Diurnal (Nonmonosymptomatic): Incontinence during both daytime and nighttime

Prevalence:

5%–10% among 5-year-olds
3%–5% among 10-year-olds
Around 1% among individuals 15 years or older

Case Study: Angelo

Demographics:

7-year-old boy
Parents concerned about nighttime and daytime wetting, temper tantrums, behavior problems

Medical History:

No physical abnormalities
Normal developmental motor milestones
Previous evaluation by urologist: normal intravenous pyelogram, IQ above average

Behavioral Symptoms:

Frequent temper tantrums at home (2–3 times a week)
Stubborn and persistent
Oppositional behavior towards parents
Normal eating and sleeping habits
Good rapport with interviewer, anxious about performance
No aggressive behaviors during play

Diagnosis:

Enuresis (Nocturnal and Diurnal subtype)
Possible Oppositional Defiant Disorder but not enough evidence for additional diagnosis.

11.2 Encopresis

Encopresis: Diagnosis and Characteristics

Definition:

Involuntary passage of feces into inappropriate places (clothing, floor) for at least a month in children with chronological or mental age of 4 years or older
Not exclusive to medications or medical conditions causing incontinence

Symptoms:

Involuntary fecal incontinence
Fecal impaction and retention leading to overflow incontinence (with constipation)
Soiling without constipation (without overflow incontinence)
Enuresis (nighttime wetting)

Case Study: Lucas

6-year-old boy exhibiting persistent fecal incontinence since first grade
Medical workup reveals no general medical condition causing this symptom
History of constipation and soiling patterns
- Alternating constipation and diarrhea
- Regular use of laxatives
- Toilet training attempts with anxiety and distress
Soiled pants within 30 minutes after changing them
Enuresis at night
Preoccupied with death and witches
Timid and shy but becoming more assertive
Delayed developmental milestones (sitting, shuffling, walking, speaking)
Mother is timid, unsure of herself, embarrassed as a professional person
Father is reticent during interview, finds the situation difficult
Pediatric examination reveals fecal mass and soft feces in rectum

Diagnosis:

Encopresis (DSM-5, p. 357) with constipation and overflow incontinence subtype
Enuresis, Nocturnal Only (DSM-5, p. 355)

CHAPIER 12 Sleep-Wake Disorders

Sleep-Wake Disorders

Introduction:

Most individuals experience sleep problems at some point due to stress or external factors
When sleep problems persist and interfere with daily functioning, a DSM-5 Sleep-Wake Disorder may be appropriate
Individuals present with complaints about the quality, timing, and amount of their sleep, resulting in daytime distress and impairment

Sleep Stages:

There are five distinct stages of sleep:
1. Rapid Eye Movement (REM) Sleep
2. Four stages of Non-Rapid Eye Movement (NREM) Sleep:
  - Stage 1 NREM sleep
  - Stage 2 NREM sleep
  - Stages 3 and 4 NREM sleep
REM sleep occurs cyclically throughout the night, alternating with NREM sleep every 80-100 minutes
REM sleep increases in duration toward the morning

Measurement of Sleep Stages:

Polygraphy: measures brain waves, blood oxygen level, heart rate, breathing, and eye/leg movements during sleep
Used to diagnose certain DSM-5 Sleep-Wake Disorders (e.g., REM Sleep Behavior Disorder)

DSM-5 Sleep-Wake Disorders:

Insomnia Disorder: dissatisfaction with sleep quality or quantity, difficulty initiating/maintaining sleep, early-morning awakening
Hypersomnolence Disorder: excessive daytime sleepiness, unrefreshing prolonged main sleep episodes, difficulty being awake after abrupt awakening
Narcolepsy: recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping during the same day
- Includes Cataplexy: bilateral loss of muscle tone
- Includes Abnormal laboratory testing (e.g., REM sleep intrusion into non-REM sleep)
Obstructive Sleep Apnea: laboratory evidence of at least 5 obstructive apneas/hypopneas per hour of sleep, daytime fatigue
Circadian Rhythm Sleep-Wake Disorders: problem with the timing of sleep due to alteration or misalignment between circadian rhythm and sleep-wake schedule
Parasomnias: abnormal movements, behaviors, emotions, perceptions, or dreams during sleep (e.g., sleepwalking, nightmares, REM Sleep Behavior Disorder)
Restless Legs Syndrome: urge to move the legs, often accompanied by uncomfortable sensations in the legs, primarily at night
Substance/Medication-Induced Sleep Disorder: persistent and severe sleep disturbance due to direct effects of substances or medications on the central nervous system

Other Sleep Disorders:

Narcolepsy: a neurological condition involving the loss of the brain's ability to regulate sleep-wake cycles normally
Breathing-Related Sleep Disorders: sleep disruption caused by abnormal breathing during sleep (e.g., Obstructive Sleep Apnea Hypopnea, Central Sleep Apnea, Sleep-Related Hyperpnea)
- These must be ruled out when a person presents with excessive daytime sleepiness

12.1 Insomnia Disorder

Insomnia Disorder

Characteristics:

Dissatisfaction with amount or quality of sleep
Difficulty initiating, staying asleep, or waking up too early
Frequency requirement: at least 3 nights a week
Duration requirement: minimum of 3 months
Clinically significant distress or impairment in functioning
Can coexist with other disorders or medical conditions

Symptoms:

Nighttime sleep difficulties
Fatigue, daytime sleepiness
Impaired cognitive performance
Difficulties with attention, concentration, memory
Irritability, mood lability
Depressive or anxiety symptoms

Prevalence:

About one-third of adults report insomnia symptoms
Only 6%-10% meet DSM-5 requirements for diagnosis
More common in women than men (gender ratio: approximately 1.5 to 1)

Case Study: "High-Strung" Ms. Harrington

Long-standing insomnia symptoms
Difficulty falling asleep, frequent awakenings, unable to return to sleep
Frequency and severity clinically significant
Contributing factors: workday stressors, late-night alcohol intake
Diagnosis: Insomnia Disorder (DSM-5)

Impact:

Daytime fatigue, impaired cognitive performance
Irritability, mood lability
Difficulties with attention, concentration, memory
Depressive or anxiety symptoms.

12.2 Hypersomnolence Disorder

Hypersomnolence Disorder

Symptoms:

Excessive sleepiness during daytime despite adequate nighttime sleep (at least 7 hours)
Compelled to nap at inappropriate times: work, meals, conversations, driving
Daytime naps provide no relief from symptoms
Not feeling refreshed after long sleep periods (e.g., 9 hours or longer)
Sleep inertia or sleep drunkenness following sleep episodes or naps

Diagnosis:

Minimum frequency of at least three times per week for hypersomnolence symptoms
Minimum duration of 3 months and causing clinically significant distress or impairment
Separate diagnosis given only if symptoms are a focus of clinical attention

Occurrence:

Approximately 5%-10% of individuals seeking consultation for daytime sleepiness are diagnosed with Hypersomnolence Disorder
Equal frequency in males and females

Case Study: Jerome Coopersmith

Excessive sleepiness since age 21
Regularly sleeps from 10:15 PM to 7:30 AM, takes naps between 9:00 and 10:15 AM, and 1:30 and 2:00 PM, irregularly in the evening
No symptoms suggestive of Narcolepsy or Breathing-Related Sleep Disorders
Organized, motivated individual with no significant medical history or substance use
Impaired daytime vigilance, normal time interval to sleep onset during polysomnography
Diagnosis: Hypersomnolence Disorder (DSM-5, p. 368) in the absence of other associated conditions.

Cry Me a River

Alison Campbell's Case

Background:

Alison Campbell, 38-year-old clerical worker
Suffers from disabling sleep problem for 11 years
Goes to bed at 6:00 PM and sleeps until 7:00 AM
Driver's license suspended due to falling asleep while driving

Symptoms:

Groggy and "out of it" upon waking
Frequently falls asleep on buses
Takes a sales job to stay awake during evenings
Sleeps all day on weekends, except for necessary activities
No signs of sleep disorders like snoring, nightmares, or muscle tone loss
Required 6-7 hours of sleep before the onset of problem

Self-medication:

Consumes up to 10 cups of coffee and 2 liters of cola daily

Psychiatric History:

Depression since age 13
Severe crying spells in office with no time to hide
Trouble concentrating, getting little pleasure from work
Angry and pessimistic feelings, diabetic and overweight
Previously treated for depression with psychotherapy and antidepressants
Fell asleep during evening group therapy sessions

Diagnosis:

Recurrent depression (Major Depressive Disorder)
Hypersomnia as a symptom of depression
No evidence of other sleep disorders or substance use causing hypersomnia.

12.3 Narcolepsy

Narcolepsy

Definition: Chronic neurological disorder involving poor control of sleep-wake cycle, characterized by excessive daytime sleepiness and uncontrollable bouts of falling asleep during the day.

Symptoms:

Daytime sleepiness with brief episodes lasting seconds to minutes (sleep attacks)
Cataplexy: Sudden loss of muscle tone precipitated by emotional reactions
- Affects neck, jaw, arms, legs, or whole body
- Head bobbing, jaw dropping, complete falls
Sleep paralysis: Temporary inability to talk or move upon awakening or falling asleep
Vivid hallucinations during transitions from sleep to wakefulness (hypnagogic) and vice versa (hypnopompic)

Diagnosis:

At least three lapses into sleep per week for 3 months + cataplexy episodes
Hypocretin deficiency or shortened REM latency on polysomnography

Characteristics of Narcolepsy:

Onset in childhood, adolescence, or young adulthood
Quite rare, affecting less than 0.05% of the general population

Case Study: Nora Thompson

Severe daytime sleepiness leading to catnaps
Episodes of cataplexy triggered by emotional arousal
Sleep paralysis and vivid hallucinations during sleep transitions
Delayed bedtimes, forgetfulness, automatic behaviors
Previous treatment with nortriptyline, dextroamphetamine, and zolpidem
Gradual improvement after record keeping and psychotherapy.

12.4 Obstructive Sleep Apnea Hypopnea

Obstructive Sleep Apnea Hypopnea (OSAH)

Definition: A breathing-related sleep disorder characterized by physical blockage of airflow during sleep, resulting in recurrent periods of partial or complete obstruction and decreased oxygen saturation.

Symptoms:

Chronic reduction of overnight blood oxygen
Long-term consequences: high blood pressure, heart disease, stroke, diabetes, depression
Daytime sleepiness, fatigue, moodiness, morning headaches

Diagnosis:

Polysomnography (overnight stay in sleep lab)
Five or more obstructive apneas or hypopneas per hour of sleep
Sleep-related breathing disturbances, such as snoring, snorting/gasping
Complaints of daytime sleepiness, fatigue, unrefreshing sleep
Absence of normal periods of deep sleep on polysomnogram

Prevalence: Affects at least 1%-2% of children, 2%-15% of middle-aged adults, and over 20% of older individuals. Male-to-female ratio ranges from 2:1 to 4:1. Associated with obesity.

Case Study: Thomas Grim

46-year-old advertising salesman and writer with sleep apnea
Snoring, pauses in breathing lasting 10-15 seconds during sleep
Restless during longer periods of not breathing
Groggy upon waking, daytime sleepiness, headaches
Diagnosed with severe OSAH through polysomnography and daytime cognitive testing
Deviated nasal septum, enlarged pharyngeal structures, collapsed pharyngeal walls
Treated with Continuous Positive Airway Pressure (CPAP) therapy for relief of sleep apnea symptoms.

Impact on Quality of Life: Chronic excessive daytime sleepiness due to nocturnal breathing pauses interferes with daily activities and reduces overall quality of life. Patient's motivation, diet, and compliance with treatment are essential for successful management of OSAH.

12.5 Circadian Rhythm Sleep-Wake Disorders

Circadian Rhythm Sleep-Wake Disorders

Overview:

Circadian rhythms controlled by an internal body clock in the hypothalamus
Primarily controls sleep-wake cycle, influencing desire and ability to fall asleep
Mismatch between internal body clock and external environment can disrupt sleep patterns

Types of Circadian Rhythm Sleep-Wake Disorders:

Delayed Sleep Phase Type (DSP):
- Person's tendency to feel sleepy is delayed relative to conventional bedtimes
- Wakes up later in the morning and has difficulty falling asleep earlier
Advanced Sleep Phase Type (ASP):
- Person experiences sleepiness several hours earlier than normal
Irregular Sleep-Wake Type:
- Lack of discernible circadian rhythm, with no major sleep period or consistent pattern
Non-24-Hour Sleep-Wake Type:
- Pattern of sleep-wake cycles not synchronized to the 24-hour environment
- Consistent daily drift of sleep onset and wake times
Shift Work Type:
- Frequently rotates shifts or works at night
- Difficulty adjusting to changes in schedule

Case Studies:

The Director (DSM-5, p. 390):
- Mr. Neeley exhibits a Delayed Sleep Phase Type
- Mismatch between his normal circadian sleep-wake pattern and societal expectations
Evening Shift (DSM-5, pp. 390-391):
- Mr. Symanski's sleep rhythm persists despite working evening shift
- Insomnia due to misalignment between circadian rhythm and work schedule demands

12.6 Non-Rapid Eye Movement Sleep Arousal Disorders

Non-Rapid Eye Movement Sleep Arousal Disorders

Types:

Sleepwalking Type:
- Repeated occurrence of incomplete awakening from non-REM sleep (stage 3 or 4)
- Common in children, more likely to occur when sleep deprived
- May involve benign behaviors like sitting up, looking awake, and walking around
- Unresponsive to efforts to communicate, difficult to awaken
- Can engage in sexual activity or sleep eating
Sleep Terror Type:
- Recurrent episodes of abrupt physical arousal during non-REM sleep
- Begin with panicky scream
- Frightened expression, signs of intense anxiety (rapid heartbeat, rapid breathing, sweating)
- Unresponsive to efforts to comfort or awaken
- No memory of the episode afterward

Characteristics:

Occur during first third of major sleep episode
Amnesia for episodes upon awakening
No evidence of impairment minutes after awakening
Isolated or infrequent episodes common in general population

Prevalence:

Sleepwalking: 10%-30% children, 29% adults (4% frequent)
Sleep terrors: 40% children at 18 months, 20% at 30 months, 2% adults

Diagnosis:

DSM-5 diagnosis requires episodes to cause clinically significant distress or impairment
Prevalence of Sleepwalking Type likely in the range of 1%-5%

Case Studies:

Meghan: 11-year-old girl experiencing sleepwalking episodes with amnesia and unresponsiveness
Matthew: 8-year-old boy experiencing sleep terror episodes with intense anxiety, disorientation, and unusual behaviors.

12.7 Nightmare Disorder

Nightmare Disorder

Characteristics:

Repeated awakenings from major sleep period or naps
Detailed recall of extended, frightening dreams
Threats to survival, security, or self-esteem
Rapid orientation and alertness upon awakening
Occur during REM sleep stages (more common in second half)
Onset between ages 3-6 years, most severe in late adolescence/early adulthood
Relatively common, occurring at least once a month in 6% of adults

Diagnostic Criteria:

Significant distress or impairment from nightmares
Awakenings result in avoidance of sleep, excessive daytime sleepiness, poor concentration, depression, anxiety, or irritability

Case Study: "Bad Dreamer" (Mrs. Cobiella)

Suffers from nightmares every night since teenage years
Denies sleep disorders, such as Narcolepsy or Sleep Paralysis
No history of trauma exposure, medication use, substance abuse, or mental disorders
Normal cognitive functioning, except for 3 mistakes on serial 7s test
No reports of nightmares during sleep recording

Treatment Approach:

Psychotherapy to control dream content through lucid dreaming routine
Trials of antidepressant and anticonvulsant medications

12.8 Rapid Eye Movement Sleep Behavior Disorder

Rapid Eye Movement (REM) Sleep Behavior Disorder

Symptoms:

Muscle paralysis during REM sleep is incomplete or absent
Acting out of dreams: vocalizations, shouting, screaming, physical behaviors (falling, jumping, flying, punching, hitting, kicking)
Often confusing for NREM Sleep Arousal Disorders (sleepwalking or terrors) due to rapid alertness upon awakening

Diagnosis:

Persistent muscle activity during REM sleep, occasionally associated with vocalizations and twitching
No seizure activity on EEG that can explain the clinical behaviors

Causes:

Adverse reactions to certain drugs or drug withdrawal
Associated with older age and neurodegenerative disorders: Parkinson's disease, Lewy body dementia
Affects approximately 0.5% of individuals in general population
Mostly affects males over age 50

Case Study: Ethan Bonner

65-year-old married English professor with sleeping disturbances
Progressive disruption of sleep due to vocalizations, shouting, and increasing motor behaviors
Fell out of bed during an episode, sustaining head injury
Wife reported action-packed dreams with themes of being chased or attacked
Neurological examination unremarkable except for mild postural instability and gradual symptoms of Parkinson's disease (tremor, rigidity, bradykinesia)
Formal polysomnographic study revealed persistent muscle activity during REM sleep

Treatment:

Heavy draperies over bedroom windows to prevent injury from falling out of bed
Removal of bedside furniture
Infrared alarm for bedroom door
Treatment with clonazepam and melatonin, with some improvement in symptoms but continued medication use and referral to Parkinson's disease clinic.

12.9 Restless Legs Syndrome

Restless Legs Syndrome (RLS)

Neurological disorder characterized by:
- Throbbing, pulling, creeping, or unpleasant sensations in the legs
- Uncontrollable urge to move them
Symptoms occur primarily at night during relaxation or rest
Affects both legs but can involve other parts of the body (arms, torso, head, phantom limbs)
Relieved by movement, which temporarily alleviates discomfort
Prevalence rates vary from 2% to 7.2%, depending on criteria used (DSM-5)
Affects both men and women, but more common in women with a twice-as-high incidence rate
Can begin at any age, with symptoms becoming more frequent and lasting longer with age
Up to 90% of people with RLS also experience periodic limb movements in sleep (PLMS)

Case Study: Mrs. Bianchi

Referred for depression and anxiety treatment
Initially prescribed escitalopram and diphenhydramine
Suffered from insomnia, worsening after taking escitalopram
Unable to fall asleep due to irresistible urge to pace and uncomfortable sensations in her legs (RLS)
Symptoms described as "bugs crawling"
Urgency starts in the late evening, worsens during rest or inactivity, and subsides with movement
Diurnal pattern, more focused on legs than other parts of the body
Exacerbated by alcohol consumption
Gabapentin treatment effectively subsidized symptoms
RLS diagnosis confirmed based on DSM-5 criteria: urge to move starts in the late evening, relief from movement, occurs at least three times a week for 3 months, distress or impairment in functioning, not attributable to another mental disorder or medical condition, or drug abuse or medication.

12.10 Substance/Medication-Induced Sleep Disorder

Symptoms:

Insomnia: difficulty falling asleep or maintaining sleep, frequent awakenings during the night, nonrestorative sleep
Daytime sleepiness: excessive sleepiness or fatigue during daytime hours
Parasomnia: abnormal behavior occurring during sleep (e.g., nightmares)

Diagnosis:

Substance/Medication-Induced Sleep Disorder is diagnosed when an individual has a prominent sleep disturbance that is the direct physiological effect of a medication or drug of abuse

Causes:

Intoxication or withdrawal from: alcohol, caffeine, cannabis, opioids, sedatives/hypnotics/anxiolytics, stimulants (including cocaine)
Withdrawal from tobacco
Medications: adrenergic agonists and antagonists, dopamine agonists and antagonists, cholinergic agonists and antagonists, serotonergic agonists and antagonists, antihistamines, corticosteroids

Case Study: Ms. Lazarus

Frequent anxiety and upset around bedtime, difficulty falling asleep (insomnia type)
Groggy, incapacitated on awakening, missing work due to late sleep patterns
Asthma treatment regimen interfering with ability to fall asleep: aminophylline, beclomethasone inhaler, albuterol inhaler, caffeine, alcohol, short-acting sedatives
Diagnosis: Caffeine / Aminophylline/ Albuterol /Beclomethasone-Induced Sleep Disorder (DSM-5)

CHAPTER 13 Sexual Dysfunctions

Sexual Dysfunctions (DSM-5)

Description: Group of disorders characterized by a clinically significant disturbance in sexual response or pleasure
Phases and Disorders
- Desire Phase: Male Hypoactive Sexual Desire Disorder
  - Lack of erotic thoughts, fantasies, and desire for sex
- Excitement Phase: Erectile Dysfunction (Male)
  - Failure to obtain or maintain erections during sex
- Orgasm Phase: Female Sexual Interest / Arousal Disorder, Premature (Early) Ejaculation (Male), Delayed Ejaculation (Male), Female Orgasmic Disorder
  - Difficulty with orgasms or lack of sexual pleasure/sensations
Resolution Phase: No dysfunction associated
Other Sexual Dysfunctions
- Genito-Pelvic Pain/Penetration Disorder
  - Difficulties with vaginal penetration during intercourse, pelvic pain
- Substance/Medication-Induced Sexual Dysfunction
  - Direct effects on central nervous system functions
Diagnosis Considerations
- Exclusion of specific explanations (inadequate stimulation, symptom of another disorder)
- Cultural and religious factors, age
- Persistence of symptoms for at least 6 months
- Distress caused by the dysfunction
Subtypes and Contexts
- Lifetime or acquired
- Situational or generalized

13.1 Male Hypoactive Sexual Desire Disorder

Male Hypoactive Sexual Desire Disorder (HSDD)

Characteristics:

Dysfunction in the first phase of sexual response cycle: reduction or absence of erotic thoughts, fantasies, and desire for sexual activity
Men may not initiate or respond to partner's desire for sexual activity
Less troubled by condition than partners who miss out on physical affection, touch, and opportunities for procreation
May be specific to a partner or not limited to any potential partner
Approximately 20% of men are affected (DSM-5)
More common in older men: 40% among ages 65+ vs. 6% among younger men (DSM-5)

Case Study: Jim Benson

Lifelong history of minimal interest in sex
Infrequent masturbation, no masturbatory fantasies, and normal endocrinological workup
First sexual experience at high school due to group pressure
College years focused on studies with limited dating
Married at age 28, wife initially impressed by his gentlemanly behavior
Sexual desire only initiated by wife, pleasurable but happy with once a year frequency
Denies sexual fantasies or other sexual preferences
No evidence of paraphilic interests or homosexual orientation.

Diagnosis and Discussion:

Other causes for low sexual desire need to be considered before making diagnosis: medical conditions, mental disorders, medications, substance abuse, mood disturbances, etc.
Mr. Benson has normal hormone levels and does not use any medications or drugs of abuse; no evidence of depression or other mental disorders.
Lifelong nature of his low sexual desire suggests it's not caused by paraphilic interests or homosexual orientation.
DSM-5 diagnosis: Male Hypoactive Sexual Desire Disorder (HSDD) - Lifelong and Generalized subtypes apply.

13.2 Erectile Disorder

Erectile Dysfunction (ED)

Sexual dysfunction affecting men during the excitement phase of sexual activity
Characterized by difficulty obtaining or maintaining erections:
- Marked difficulty in obtaining an erection during sex
- Marked difficulty in maintaining an erection until completion
- Marked decrease in erectile rigidity
Diagnosis only given if no specific causes identified and ruled out first
- Medical causes (e.g., heart disease, diabetes, Parkinson's)
- Side effects of medications (e.g., diuretics, antidepressants)
- Substance abuse (alcohol, cocaine)
- Mental disorders (depression, PTSD)
Prevalence increases with age, particularly after 50 years old
Affects approximately 2% of men younger than 40-50 years and up to 40%-50% of men over 60-70 years.

Case Study: Paul Petersen and Annie

Couple contemplating marriage after living together for 10 months
Annie experiences Paul's persistent inability to maintain erections during intercourse for the past six months
Paul embarrassed, unsure of cause
Psychologist diagnoses Erectile Disorder based on symptoms, duration, and absence of other causes.

Treatment Approach:

Sensate focus exercises to improve physical intimacy without pressure to perform sexually.
Couple's relationship issues not deemed severe enough to preclude diagnosis of Erectile Dysfunction.

13.3 Female Sexual Interest/Arousal Disorder

Female Sexual Interest/Arousal Disorder

Diagnosis:

DSM-5 diagnosis for dysfunctions involving desire and arousal phases of female sexual response cycle

Symptoms:

Reduced or absent interest in sexual activity
Reduced or absent erotic thoughts or fantasies
Lack of initiation of sexual activity, often being unreceptive to partner's attempts
Reduced or absent sexual excitement or pleasure during sexual activity
Reduced or absent sexual interest or arousal in response to written, verbal, or visual cues
Reduced or absent genital or nongenital sensations during sexual activity

Causes:

Specific medical and substance-induced causes must be ruled out
Low estrogen levels, especially after menopause, can cause desire and arousal difficulties
Testosterone is important for female sexual functioning, and low levels are associated with low sexual desire
Certain medical conditions (diabetes, thyroid disease, cancer) can cause desire or arousal problems
Reduction in desire and arousal is a common side effect of certain medications (antidepressants, antihypertensives, anticancer drugs)

Case Study: Mrs. Diaz

45-year-old woman referred for further evaluation and treatment of low sexual desire and arousal
Experiencing perimenopause with symptoms like hot flashes, menstrual irregularity, and vaginal dryness
Gradually decreased interest in sex over time, rarely initiating and having difficulty becoming aroused when husband initiates
Sometimes experiences mild discomfort during intercourse due to insufficient lubrication
Has not achieved orgasm as easily as in the past, but still capable of orgasm with oral sex
Struggling with heavy time commitments from work and family responsibilities
Occasionally notices a "sparkle" of desire for younger male coworker, but feels guilty and confused about these thoughts
Previously took flibanserin medication without improvement and discontinued use
No signs of depression or anxiety, but resumed drinking alcohol occasionally
Treatment included cognitive-behavioral sex therapy (sensate focus) and partner involvement to enhance pleasure.

13.4 Premature (Early) Ejaculation

Premature (Early) Ejaculation

DSM-5 includes two disorders involving orgasmic functioning in males: Premature Ejaculation and Delayed Ejaculation
Premature Ejaculation:
- Defined as "ejaculation occurring during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it" (DSM-5, p. 443)
- May also apply to non-vaginal sexual activities, but specific duration guidelines not established
- Biological causes include:
  - Excess thyroid hormone
  - Inflammation and infection of the prostate or urethra
  - Nerve damage from surgery or trauma
- Men with Premature Ejaculation often complain of a sense of lack of control over ejaculation, apprehension about future encounters, decreased self-esteem, and adverse consequences for partner relationships
- It is one of the most common forms of male sexual dysfunction, with approximately 30% reporting at least one occurrence in the previous year

Delayed Ejaculation

Characterized by a marked delay in or inability to achieve ejaculation despite adequate sexual stimulation
Usually involves partnered sexual activity
DSM-5 does not define "delayed", so it is likely when the delay causes distress, frustration, or requires stopping due to fatigue, physical irritation, loss of erection, or partner request
Men with Delayed Ejaculation may be able to reach orgasm without difficulty during masturbation but have trouble during intercourse
Prevalence is unknown, but it is the least common male sexual complaint

Case Studies

No Control (Premature Ejaculation):
- Liam and Melissa Crane, a successful couple married for 15 years
- Mr. Crane has a rapid ejaculation problem that threatens their marriage
- He becomes anxious, moves quickly to intercourse, and ejaculates immediately or within a few strokes, causing wife's dissatisfaction
- Feels inadequate and guilty, unable to discuss the issue with his wife
- Diagnosis: Premature Ejaculation (DSM-5, p. 443)
In Jeopardy (Delayed Ejaculation):
- Dennis Collins, a college professor, has never been able to ejaculate during intercourse
- Able to maintain erections and stimulate partner to orgasm, but unable to reach his own orgasm
- Attitude is distant and disinterested, describing the problem as if he's an observer
- Diagnosis: Delayed Ejaculation (DSM-5, p. 424)

13.6 Female Orgasmic Disorder

Female Orgasmic Disorder

Characteristics:

Difficulty experiencing orgasm or reduced intensity of orgasmic sensations despite adequate sexual stimulation
Variability in type and intensity of stimulation required for orgasm among women
Diagnosis should only be considered if problems are experienced on almost all occasions

Normal Variability:

Many women require clitoral stimulation to reach orgasm, not during intercourse
Physiological factors like medical conditions and medications can influence orgasms

Diagnostic Considerations:

Substance / Medication-Induced Sexual Dysfunction if problems are side effects (see Section 13.8)
Approximately 10% of women do not experience orgasm throughout their lifetime

Case Study: Lola Alvarez

Inability to experience orgasms despite sufficient stimulation
Anxiety about losing control and expressing anger or hostility
No mental disorder, general medical condition, substance abuse, or medication use apparent
Persistent problem causing distress

Diagnosis:

Female Orgasmic Disorder, Lifelong, Generalized (DSM-5 p. 429)

13.7 Genito-Pelvic Pain/Penetration Disorder

Genito-Pelvic Pain/Penetration Disorder (GPPD)

Characteristics:

Difficulty having vaginal intercourse
Marked vulvovaginal or pelvic pain during intercourse or penetration attempts
Fear and anxiety about potential pain before, during, or after vaginal penetration
Involuntary tensing of pelvic floor muscles (vaginismus) during attempted penetration

Diagnostic Criteria:

Not explained by another mental disorder
No relationship distress or partner violence
No general medical condition causing pain or infertility
No medication side effect

Prevalence and Demographics:

Prevalence unknown, approximately 15% of women in North America report recurrent pain during intercourse
Diagnosed only for women, but urological chronic pelvic pain syndrome in men is a related condition

Case Study: Claire Whitaker's Story

Unable to allow vaginal penetration since marriage due to spasms and anxiety
Previous therapy helped with episodic intercourse, but fear of pregnancy remained
History of chronic endometriosis, premature birth, religious upbringing, lack of education on sexual health
Treatment included couple sessions for husband's frustration and cooperation, individual sessions, antianxiety medication, vaginal dilation exercises.

Treatment Approach:

Addressing anxiety related to vaginal penetration through therapy and medication
Gradual vaginal dilation exercises in warm water to improve comfort with body
Sensate focus exercises for pleasure without intercourse
Group therapy for nonorgasmic women for additional support.

13.8 Substance/Medication-Induced Sexual Dysfunction

Substance/Medication-Induced Sexual Dysfunctions

Wide range of medications and substances can cause sexual dysfunctions
Antidepressants: most commonly cause problems with orgasm or ejaculation, desire, and erection
- 25% to 80% of individuals report sexual side effects
- Antipsychotic medications, antianxiety agents also cause sexual side effects
- Other medications associated with sexual dysfunction: statins, blood pressure medications, histamine type 2 receptor blockers, anticonvulsant medications, hormonal contraceptives
Illicit substance use can lead to sexual problems, especially among chronic drug abusers
- Higher rates of erectile dysfunction in individuals who abuse heroin (approximately 60%-70%) compared to amphetamines or ecstasy
- Chronic alcohol abuse and nicotine abuse linked to higher rates of erectile problems
Premature ejaculation can sometimes occur after cessation of opioid use
Substance/Medication-Induced Sexual Dysfunctions are usually reversible by lowering dosage or stopping the medication

Case Study: "Bad Side Effect"

Amy Harris, 36-year-old bank officer, experiences extreme difficulty reaching orgasm
- Orgasmic capacity in her teenage years and early 20s
- Loss of sexual interest after husband's affair and non-promotion at work
- Diagnosed with Major Depressive Episode
- Treated with antidepressant medication, Paroxetine 20 mg/day
- Orgasmic difficulties worsened when dosage was increased to 40 mg/day and returned after lowering the dose again to 20 mg/day
Diagnosis: Paroxetine-Induced Sexual Dysfunction (DSM-5, p. 446)

CHAPTER 14 Gender Dysphoria

Gender Dysphoria

Definition:

Gender: publicly recognized lived role as boy or girl, man or woman
Sex: biological indicators of male and female (reproductive capacity, sex chromosomes, gonads, sex hormones, external genitalia)
Gender dysphoria: emotional and cognitive discomfort with assigned gender, distress due to incongruence between experienced/expressed gender and biological sex

Characteristics of Gender Dysphoria:

For Children (prepubescent)

Strong preference for cross-gender expressions: clothing, role-playing, toys, activities
Rejection of assigned gender toys, games, activities, dislike of own sexual anatomy
Desire for sex characteristics of experienced gender

For Adolescents and Adults

Incongruence between experienced gender and own sex: desire to be rid of own sex characteristics, have sex characteristics of other gender
Desire to be the other gender and be treated as such
Convinction that one has feelings and reactions of other gender.

Diagnostic Criteria:

DSM-5 presents two lists for children (prepubescent) and adults
Children's criteria are age appropriate, inferential, concrete, and specific
Adult criteria focus on distress as the clinical problem rather than gender identity itself
When there is a physical disorder of sex development, specify with "With a Disorder of Sex Development".

14.1 Gender Dysphoria in Children

Gender Dysphoria in Children

Definition:

"Marked incongruence between one's experienced/expressed gender and assigned gender" (DSM-5)
Persists for at least 6 months
Strong desire to be another gender or alternative gender

Characteristics:

Boys: preference for cross-dressing as a girl, rejection of masculine toys/activities
Girls: preference for boyish attire, resistance to feminine clothing
Strong preferences for cross-gender roles in play and fantasy life
Dislike of own sexual anatomy, desire for different characteristics

Diagnosis:

Distinguish from nonconformity to gender role behavior
Diagnose when distress and impairment occur

Prevalence:

Rare, more common in boys than girls
Onset usually between ages 2-4
Persistence rates vary, up to 50% in girls

Case Study: Rocky

8-year-old boy wanting to be a girl
Preferences for female roles and toys
Cross-dressing behavior
Parents report normal development, no overt psychopathology
Family history of younger sister's medical needs may have contributed.

Assessment:

Persistent identification as female
Desire to be a girl
Preoccupation with stereotypical female activities and toys
Aversion towards male toys/activities.

14.2 Gender Dysphoria in Adolescents

Gender Dysphoria in Adolescents and Adults

Characteristics of Gender Dysphoria:

Marked incongruence between experienced/expressed gender and primary/secondary sex characteristics
Discomfort with or desire to change/prevent development of:
- Primary sex characteristics (e.g., penis, testes, ovaries, vagina)
- Secondary sex characteristics (e.g., breasts, fat distribution, muscle mass, facial hair)
Strong desire to have sex characteristics of the other gender
Belief that has typical feelings and reactions of the other gender
May attempt to hide secondary sex characteristics or take hormones/surgery to align with desired gender

Onset and Sexual Orientation:

Early onset: Most common in biological males, often associated with sexual attraction to men
Late onset: May engage in transvestic behavior for sexual excitement, attracted to women or other posttransitional males
In biological females, most commonly early onset, may later seek hormones/surgery after identifying as lesbian

Distinction from Transvestic Disorder:

Cross-dressing behavior in Gender Dysphoria is part of overall pattern of gender expression
Transvestic Disorder involves cross-dressing for sexual arousal, rarely occurs in females

Additional Challenges:

Significant interpersonal problems, including sexual relationship difficulties
Low self-esteem, risk of other mental disorders (e.g., Major Depressive Disorder), school/work challenges
Difficulty accessing accepting and informed medical/psychological care

She Wants to Be a Boy

Kelly's Case Study

Background:

16-year-old girl from British Columbia, Canada
Suggested to a gender identity clinic by family physician
Parental agreement and participation
Longstanding desire to be a boy since age 2
Relationship with another girl, Anna, precipitated referral

Symptoms:

Discomfort with being female
Hates menstruation and wearing a bra
Desire for gender reassignment surgery (mastectomy, hormone injections)
Unsure about penis construction possibility
Preference to be seen as "human being"
Quit school after 7th grade
Training in military youth group
Delight in using AK-47 assault rifle
Attracted to "gory things, blood, and living dangerously"
Uncertain about sexuality (lesbianism, heterosexuality)
No history of sexual experiences or masturbation
Physical examination: XX chromosomes, normal testosterone level, no signs of intersex condition

Diagnosis:

Gender Dysphoria in Adolescents and Adults (DSM-5)
Strong and persistent desire to be a male
Desire for gender reassignment surgery
Masculine appearance and behaviors
Discomfort with being female.

Follow-up:

Continued preoccupation with changing her gender
Ambivalent gender role (masculine occupation, but no clear identity)
Application to adult gender identity clinic for reassignment surgery
Failed to keep appointment.

Living as a Man

Case Study: Charles Northrop

Background:

25-year-old patient from North Dakota
Born female, now identifies as "Charles Northrup"
Lived socially and employed as a man for 3 years
Housemate, economic provider, and "husband-equivalent" for a bisexual woman
Affectionate bond with her children

Appearance:

Passed as a "not very virile man"
Low but not baritone voice
Bulky clothing to conceal tightly bound, flattened breasts
Strap-on penis produced masculine bulge in pants

Medical History:

Unsuccessfully tried to obtain mastectomy, hysterectomy, oophorectomy, and testosterone prescription
Experienced distress and incongruence with primary female sex characteristics

Desired Outcomes:

Hopes for successful phalloplasty (surgical construction of a penis) as long-term goal
Wanted to eliminate primary female sex characteristics and acquire male secondary traits

Diagnosis:

Gender Dysphoria in Adolescents and Adults (DSM-5, p. 452) suggested diagnosis

Characteristics of the Disorder:

Desperate desire to change primary female sex characteristics into male traits
Strong and persistent cross-gender identification
No evidence of physical intersex or genetic abnormality
Onset often occurs in late adolescence or early adulthood

CHAPTER 15 Disruptive, Impulse-Control, and Conduct Disorders

Disruptive, Impulse-Control, and Conduct Disorders

Characteristics:

Characterized by problems in self-control of behavior and emotions
Behaviors violate the rights of others or go against social norms/authority
Underlying personality dimension: externalizing - acting negatively toward people or things in environment

Disorders:

Conduct Disorder: Poor behavioral regulation, aggressive impulses, and violation of rights
Intermittent Explosive Disorder: Uncontrolled emotions, recurrent behavioral outbursts
Oppositional Defiant Disorder: Angry/irritable mood, argumentative or defiant behavior
Pyromania: Deliberate fire setting, tension before act, fascination with fire
Kleptomania: Recurrent failure to resist impulse to steal, pleasure at time of theft
Substance Use Disorder: Behavioral loss of control over substance use (classified elsewhere in DSM-5)
Gambling Disorder: Behavioral loss of control over gambling (classified elsewhere in DSM-5)

Age of Onset:

Conduct Disorder: Childhood or adolescence
Intermittent Explosive Disorder: Not specified
Opposite Defiant Disorder: Childhood

Additional Information:

These disorders are related to externalizing dimension, where individuals express problems outwardly
Pyromania involves tension-relieving function
Kleptomania involves recurrent failure to resist impulse
Substance Use Disorder and Gambling Disorder also involve behavioral loss of control and classified elsewhere in DSM-5.

15.1 Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD)

Definition:

Pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness persisting for at least 6 months
Causes distress or impairs functioning

Symptoms:

Angry or irritable mood:
- Frequent loss of temper
- Being easily annoyed or angry
- Resentment
Argumentative/defiant behavior:
- Arguments with adults/authority figures
- Refusal to comply with requests
- Deliberate annoyance of others
- Blaming others for mistakes
Vindictiveness or spitefulness

Diagnostic Considerations:

Symptoms not entirely explained by sibling rivalry
Four or more symptoms present within preceding 6 months, causing significant impairment in functioning
Exceeds normative behavior for age, gender, and culture

Severity:

Mild: One social setting
Moderate: Two or more social settings
Severe: Three or more social settings

Onset:

Earliest symptoms appear in preschool years, rarely after early adolescence

Comorbidities:

Conduct Disorder: May develop from defiant types of ODD
Anxiety or Depressive Disorders: Angry, irritable types of ODD may predispose to these disorders

Prevalence:

Average estimated prevalence is 3.3%
Slightly more common in males before adolescence but inconsistent difference in adults.

No Brakes

Jeremy's Behavior Issues

Background:

Brought to mental health clinic by mother due to disruptive behavior at school
Suspended from school for swearing at teacher, reprimanded by police for riding bike unsafely, and broke a window with his bike
Difficulty managing behavior since nursery school

Problems Escalated:

Teasing, kicking other children, tripping them, calling names
Bad-tempered and irritable, but sometimes charming and helpful
Unpredictable moods, upsets easily, shouts and screams
Spiteful and mean toward younger brother

Behavioral Patterns:

Defiant and rude to mother at times, needs multiple reminders to comply
Good concentration, but tells minor lies
High energy level, not aimlessly hyperactive
Persistent argumentative, irritable, defiant, annoying, and resentful behaviors

Diagnostic Considerations:

Conduct Disorder: Does not violate basic rights or display serious forms of behavior
Attention-Deficit/Hyperactivity Disorder (ADHD): High energy level but no other characteristics
Oppositional Defiant Disorder (ODD): Persistent argumentative, irritable, defiant, annoying, and resentful behaviors. Severity is Severe as behaviors occur at home, school, and with peers. Some clinicians consider ODD a mild form of Conduct Disorder, but many children with the disorder do not develop more serious behavioral problems.

Special Dinners

Caleb's Behavioral Issues

Parents brought son to child psychologist due to marital conflict over behavior
Mother complained father "overindulged" Caleb, allowing delayed bedtimes and multiple meal choices
Caleb became easily annoyed, argued with parents, and refused to follow rules
No evidence of property destruction, excessive lying, or stealing
Child appeared cheerful but minimalized problems during interview

Diagnosis:

Oppositional Defiant Disorder (ODD) based on confined home behavior
- Mild severity as behaviors not apparent at school or with peers
No signs of Conduct Disorder, Schizophrenia, or Autism Spectrum Disorder.

Behavioral Patterns:

Frequent temper tantrums and arguing with parents
Delayed bedtimes due to resistance to going to bed
Refusal to eat prepared meals, insisting on multiple choices

Impact on Family:

Strain on already shaky marriage due to conflict over Caleb's behavior
Father's inability to set appropriate limits perpetuating ODD.

Recommended Treatment:

Family therapy to address the relational component and establish appropriate limits.

15.2 Intermittent Explosive Disorder

Intermittent Explosive Disorder (IED)

Features:

Recurrent emotional and behavioral outbursts reflecting failure to control aggressive impulses
Outbursts can be verbal or physical

DSM-5 Criteria:

Minimum frequency:
- Verbal assaults or physical assaults without significant harm: twice weekly for 3 months
- Physical assaults causing harm or property damage: at least 3 episodes in a year
Outbursts must be:
- Out of proportion to provocation/stressor
- Impulsive, not premeditated or for personal gain
- Cause distress, impairment, or legal/financial consequences

Associated Disorders:

Bipolar Disorder (Chapter 3)
Disruptive Mood Dysregulation Disorder (Section 4.1)
Psychotic Disorder (Chapter 2)
Personality Disorders: Antisocial or Borderline (Section 18.5, 18.1)
Other mental, medical, substance-related causes rule out IED diagnosis

Additional Diagnoses:

ADHD, Conduct Disorder, Oppositional Defiant Disorder, Autism Spectrum Disorder if severe and requiring additional attention

Prevalence:

1-year prevalence in the US: 2.7%
More common in younger adults, rarely begins after age 40
Affects men slightly more often than women
Has devastating social, occupational, financial, and legal consequences

Hothead Harry, Gnome Assassin

Background

Marketing director named Harry Axelrod
Called anger and aggression treatment clinic after heated argument with fiancée
Destroyed lawn gnome during dispute over mowing the lawn
Frequent aggressive outbursts throughout adulthood
- Kicked in TV screen, smashed car window, threw phone at wall
- Approximately three arguments and one act of property destruction per week
- Ruined past relationships, alienated coworkers, jeopardized job
Anger issues were not new for him or his family

Childhood

Grew up in middle-class suburban family
Father had a "hair trigger" and would berate him in front of friends
Family functions turned into "war zones" due to verbal and physical aggression
Academically successful but struggled with getting along with classmates
Occasional destruction of small toys or school supplies when angry or frustrated

Adolescence

Frequent arguments (1-4 per week) with friends, classmates, family members
Nicknamed "Hothead Harry" after breaking a chair in response to poor test score
Left college after 6 months due to issues with coworkers and the company

Adulthood

Worked at marketing firm for 3 years but left due to interpersonal problems
Dated woman for 3 years and broke up over his irritability and outbursts
Considered seeking help but did not feel there was a "pill to stop you from being an asshole"
Clinical depression for approximately 1 month after breakup
Occasional drinking, but never felt it was out of control

Workplace Issues

Verbal outbursts alienated coworkers
Grabbed and pushed a coworker after altercation, mandated to see employee assistance program counselor for five sessions

Current Relationship

Tumultuous relationship with fiancée
- Warned him to control his anger
- Pattern of guilt, apology, and defensive verbal aggression
Admitted he never threatened or put hands on her but felt "not that bad a guy" due to his temper.

Calisthenics

Ms. Fortunato's Case History

31-year-old housewife sought help for temper outbursts, increasing marital discord
Difficulty with husband's suspected affair, ruminated angrily during ruminative episodes
Attempted to "discharge tension" through calisthenics, still lost control upon husband's return
Violent outbursts: threw glass at husband, banged walls, put hand through window
Felt headache and "strangeness" before losing control, became violent during husband's presence
Depressed and remorseful after outbursts, recognized they were "crazy" but justified
Overzealous discipline towards children during ruminative periods, slapped them harshly
Episodes increasing in frequency over past year, 1-2 per month

Diagnostic Considerations

Intermittent Explosive Disorder (IED): outbursts result in serious assault or property damage
Nonspecific abnormality on EEG suggests underlying central nervous system issue
Potential for child abuse due to violent behavior towards children
Traumatic Brain Injury (TBI) or Chronic Traumatic Encephalopathy (CTE) considered as possible causes, but no history of severe head trauma.

Discussion and Conclusion

Ms. Fortunato's behavior suggests Intermittent Explosive Disorder (IED)
Diagnosis hinges on the frequency and severity of outbursts, potential for child abuse
EEG abnormality may indicate underlying central nervous system issue
Further testing needed to rule out other neurological disorders like TBI or CTE.

15.3 Conduct Disorder

Conduct Disorder

Definition:

Repetitive and persistent pattern of behavior violating others' rights or societal norms (DSM-5, p. 469)

Diagnostic Criteria:

Minimum of three behaviors from four groups present within a 12-month period
Impairment in social, academic, or occupational functioning

Groups and Behaviors:

Aggression to people and animals: bullying, threatening, intimidating; physical fights; using weapons; cruelty towards people or animals; mugging, extortion, armed robbery; forcing sex
Destruction of property: deliberate fire setting; destructive behavior in other ways
Deceitfulness or theft: breaking and entering; lying or conning; stealing non-trivial items without confrontation
Serious violations of rules: staying out past curfew; truancy; running away from home

Subtypes:

Childhood-Onset Type: symptoms appear before age 10, more aggressive behavior, poorer prognosis
Adolescent-Onset Type: no symptom before age 10, less severe behavior, better prognosis

Additional Specifiers:

With Limited Prosocial Emotions: callousness, lack of empathy, insincere emotions, poor prognosis

Severity:

Mild: few conduct problems causing minor harm to others
Moderate: more conduct problems with some harmful effects on others
Severe: many conduct problems causing considerable harm to others

Prevalence:

2%-10%, median of 4% among children and adolescents (one-year prevalence)
Higher in males than females
Implications: school suspension/expulsion, legal difficulties, substance abuse, risky behavior, serious impairments for individual and society.

Killer

Pattern of Antisocial Behavior: "Killer" Alfred's Case

Behavioral Pattern:

Staying out late at night
Truancy from school
Engaging in intimidation and physical aggression with peers
Setting fires and destroying property (breaking windows)
Horrific killing of a young girl

Diagnostic Indications:

Severe Conduct Disorder, Childhood-Onset Type (DSM-5, p. 469)
Lack of remorse
Callous lack of empathy
Lack of concern about school performance
Unemotional reaction to actions

Symptoms:

With Limited Prosocial Emotions for Conduct Disorder

Prognosis:

Grave prognosis.

Shoelaces

Javier's Case Summary

Background:

Age: 16 years old
Admitted to hospital after serious suicide attempt
History of conduct disorder with antisocial behavior (onset after age 10)
- Truancy from school
- Threatening principal, leading to expulsion
- Purchasing and using illegal drugs
- Running away from home
- Breaking and entering, car theft

Conduct Disorder:

Diagnosis: Conduct Disorder, Adolescent-Onset Type (DSM-5)
Severity: Severe
Specifier: No "With Limited Prosocial Emotions"

Major Depressive Episode:

Symptoms: Depressed mood, many characteristic symptoms
Onset: 2 weeks before suicide attempt
Additional diagnosis: Major Depressive Disorder, Single Episode, Severe (DSM-5)

Substance Use Disorders:

Cannabis Use Disorder (DSM-5)
Other Hallucinogen Use Disorder (LSD) (DSM-5)
Sedative, Hypnotic, or Anxiolytic Use Disorder (DSM-5)
Manifestations indicate at least Mild Substance Use Disorder.

Complications:

Co-occurring mental disorders requiring treatment.

Seizure

Rene's Case: Behavioral Problems and Seizure Incident

Background:

Rene, a 16-year-old high school junior, hospitalized for behavior problems since age 12.
History of truancy, petty thefts, marijuana use, and setting a fire in a vacant lot leading to court involvement and psychiatric ward admission.
Parents unable to control her.

Hospitalization:

Befriended other adolescents but demanding and emotionally volatile.
Stormed out of community meetings when disagrees with decisions.
Attempted to monopolize activities, then became angry and pouty when not permitted to do so.
Insecure and dependent despite superficial bravado.

Seizure Incident:

Refused pass to go out of hospital, stormed back to her room.
Violent shaking with jerking movements in pelvis, arms, legs, and rolling eyes upward.
No urinary or fecal incontinence.
Fully alert when asked questions by nurse 15 minutes later.
Walked to examining room for doctor evaluation.

Diagnostic Challenges:

Possible diagnostic options: Conversion Disorder (Functional Neurological Symptom Disorder), Factitious Disorder, or Malingering.
No evidence of voluntary control over the seizure symptoms, so prefer to assume it was not faked.
Diagnosis: Provisionally, Conversion Disorder with Acute Episode and With Psychological Stressor.

Additional Considerations:

If Rene acknowledges faking fit for attention or privileges, diagnose Malingering.
Unlikely event of exhibiting fake fits without purpose, then diagnosis changes to Factitious Disorder Imposed on Self.

15.4 Pyromania

Pyromania:

Defined as deliberate and purposeful fire setting on multiple occasions (DSM-5)
Preceded by tension or emotional arousal, pleasure, gratification, or relief upon setting the fire
Fascination with fire and its contexts: watching fires, false alarms, spending time at fire department
Not for financial, political, criminal purposes, anger/vengeance, delusion/hallucination, impaired judgment
Rare mental disorder, most cases not due to Pyromania
Occurs more often in men
In adults: monetary gain, improve living circumstances, express anger or vengeance, conceal criminal activity, attract attention
When related to a mental disorder: Substance Intoxication, Major Neurocognitive Disorder, delusion/hallucination
Children and adolescents: developmental experimentation (playing with matches), Conduct Disorder, Intellectual Disability.

Brrr

Kelvin's Case Study

Background:

Attractive 6-year-old boy
Single mother brought him to emergency room due to fire setting behavior
Several incidents over the past year and a half
Fears mother won't be able to control or prevent further fires
Mother reports Kelvin sets fires out of anger towards her

Symptoms:

Sets fires with various methods: plastic sheets, lighters, matches
Began fascinated with setting fires two years ago
Unhappy in school, no new friends outside school
Difficult to discipline, ignores mother

Psychological Evaluation:

Initial guarded and distrustful behavior
Play revolves around themes of fires getting bigger and out of control
Affect is either inappropriate (laughter) or blunted (emotionless) when discussing fires
Nonchalant and unconcerned about "command hallucinations" from "man in his head"
Denied suicidal ideation, but mother reported recent wish to die

Diagnosis:

Pyromania according to DSM-5 (476)
Tension or affective arousal before the act can only be inferred
Possible command hallucination raising question about responsibility for behavior.

15.5 Kleptomania

Kleptomania

Characteristics:

Recurrent failure to resist impulses to steal objects not needed for personal use or monetary value (DSM-5, p. 478)
Increasing sense of tension before stealing
Pleasure, gratification, or relief after committing act
Not an act of anger or vengeance
Not caused by delusion or hallucination
Not explained by another mental disorder (e.g., manic episodes, antisocial behavior)
Individuals attempt to resist impulse and are aware that stealing is wrong
Frequent fear of being apprehended and guilt about thefts

Demographics:

More common in females than males
Rare mental disorder

Onset:

Can begin at any time from childhood to late adulthood
Most common onset during adolescence

Consequences:

Serious legal, family, and career problems

Case Study: Lobsterman Mario Rossi

42-year-old married man with no criminal record or particular need for stolen lobster
shoplifting pattern of random items without specific purpose
Increasing sense of tension before stealing, relief after committing act
No other explanations for the behavior (e.g., manic episodes, antisocial behavior)
Guilt and resolve to never steal again but succumbs to impulse

Case Study: The Heiress Martha Wellington

34-year-old wealthy woman with marital problems
Periodically experiences urge to steal articles of clothing
Steals items she does not need or like, feels relief and anxiety after stealing
No evidence of other motivations or psychopathology explaining the behavior.

CHAPTER 16 Substance-Related and Addictive Disorders

Substance-Related Disorders

Drug Classes (simplified):

Depressants: alcohol, sedatives, hypnotics, or anxiolytics
Stimulants: controlled substances (amphetamine and cocaine), caffeine and tobacco
Cannabis
Hallucinogens: phencyclidine (PCP) and other hallucinogens
Opiods
Inhalants and other drugs (inhalants, anabolic steroids, etc.)

Gambling Disorder:

Presented alongside Substance-Related Disorders due to similarities in reward systems and behavioral symptoms

Substance Use vs. Induced Disorders:

Substance Use Disorder: Problems with substance use leading to impairment or distress
Substance-Induced Disorder: Psychological or behavioral symptoms caused by direct effects of the substance on the central nervous system

Co-occurrence of Disorders:

Substance Use Disorder and Substance-Induced Disorder can co-occur, but are distinct conditions

Substance Classes Associated with Specific Disorders:

Table 16-1: Depressants, stimulants, cannabis, hallucinogens, opioids, and inhalants/other drugs associated with Substance Use Disorder, Substance Intoxication, or Substance Withdrawal

Substance Use Disorders

Substance Use Disorders

Characteristics:

Cluster of cognitive, behavioral, and physiological symptoms
Individual continues using substance despite significant problems
Underlying brain circuitry change may persist beyond abstinence
Prone to repeated relapses and intense drug craving

Diagnostic Criteria (DSM-5):

Impaired control over substance use:
- Exceed own preset limits
- Persistent desire to cut down or regulate use
- Spend significant time obtaining or using the substance
Social and occupational impairment:
- Unable to fulfill major role obligations due to substance use
- Continue use despite social/interpersonal problems caused by substance use
- Give up important activities because of substance use
Risky use of the substance:
- Repeatedly use in physically hazardous situations
- Continue use despite physical or psychological problems caused by substance use
Physiological dependence on the substance:
- Tolerance (increased amount or reduced effect)
- Withdrawal symptoms when stopping use

Classes of Substances:

Depressant drugs: Hand tremor, sweating, nausea, vomiting, diarrhea, agitation, fever
Opioid drugs: Withdrawal symptoms less obvious but can involve dysphoric mood and fatigue
Stimulants or cannabis: Less obvious withdrawal, involving dysphoric mood and fatigue
PCP and other hallucinogens/inhalants: No documented significant withdrawal symptoms in humans

Medication Abuse:

If tolerance and withdrawal develop during appropriate medical treatment, do not count toward diagnosis if taken as prescribed
However, if taken at higher doses or more often than prescribed, should be considered part of the diagnosis.

Severity Levels:

Mild: 2 to 3 symptoms
Moderate: 4 to 5 symptoms
Severe: 6 or more symptoms

Remission Status:

Early Remission: No criteria met for at least 3 months but less than 12 months
Sustained Remission: No criteria met for 12 months or longer.

Substance-Induced Disorders

Substance-Induced Disorders

Types of Substance-Induced Disorders:

Substance Intoxication:
- Diagnosed during use of a substance
- Causes problematic behavioral or psychological changes
- Symptoms depend on specific substance: alcohol, sedative drugs, anxiolytic medication, caffeine
  - Alcohol: inappropriate sexual or aggressive behavior, mood lability, impaired judgment, slurred speech, incoordination, impairment in attention and memory
  - Caffeine: restlessness, nervousness, excitement, insomnia, flushed face, sweating, muscle twitching, increased heart rate, rambling flow of thought and speech
- Common among those with Substance Use Disorder but also occurs in individuals without one
Substance Withdrawal:
- Develops after prolonged use of a substance
- Characterized by substance-specific behavioral changes and physiological and cognitive disturbances
- Symptoms often the opposite of intoxication symptoms: dysphoric mood, fatigue, increased appetite (stimulants vs. depressants)
- Associated with Substance Use Disorder but can develop without one
Substance/Medication-Induced Mental Disorders:
- Potentially severe and temporary psychiatric syndromes caused by substances of abuse, medications, or toxins
- Nine specific types: Psychotic Disorder, Bipolar and Related Disorder, Depressive Disorder, Anxiety Disorder, Obsessive-Compulsive and Related Disorder, Sleep Disorder, Sexual Dysfunction, Delirium (Substance-Induced, Substance Withdrawal, Medication-Induced), Neurocognitive Disorder
- Not all combinations of substances and mental disorders exist due to specific substance effects on psychiatric symptoms.

Substance-Related Disorders in Case Examples

Substance-Related Disorders: Case Examples

Section 16.1: Depressants

Alcohol Use Disorder ("Vodka")
Alcohol Intoxication ("Joe College")
Alcohol Withdrawal ("The Reporter")

Section 16.2: Diazepam

Diazepam Use Disorder
Diazepam Withdrawal ("August Days")

Section 16.3: Stimulants - Cocaine

Cocaine Use Disorder ("Cocaine Problem")

Section 16.4: Caffeine and Tobacco

Caffeine Withdrawal ("Coffee Machine")
Tobacco Use Disorder ("Junkie")

Section 16.6: Cannabis

Cannabis Intoxication ("Freaking Out")
Cannabis Withdrawal ("Fidgety and Grumpy")

Section 16.7: Hallucinogens - Phencyclidine

Phencyclidine Use Disorder
Phencycliidine Intoxication ("Peaceable Man")

Section 16.8: Hallucinogen Persisting Perception Disorder

"A Man Who Saw the Air"

Section 16.9: Opioids

Opioid Use Disorder ("Cough Medicine")

Section 16.10: Inhalants and Other Drugs

Inhalant Intoxication ("Better Living Through Chemistry")

Section 16.11: Gambling Disorder

"Loan Sharks"

Other Substance/Medication-Induced Mental Disorders:

Substance/Medication-Induced Psychotic Disorder: "Agitated Businessman," "Threatening Voices" (Section 2.7)
Substance/Medication-Induced Bipolar and Related Disorder: "Sleepless Housewife" (Section 3.4)
Substance/Medication-Induced Sleep Disorder: "Mystery Mastery" (Section 12.10)
Substance/Medication-Induced Sexual Dysfunction: "Bad Side Effect" (Section 13.8)
Substance/Medication-Induced Delirium: "Traction," "Thunderbird" (Section 17.1)
Substance/Medication-Induced Neurocognitive Disorder: "Chief Petty Officer," "Disabled Vet" (Section 4.3)

DEPRESSANTS

Depressants

Drugs that lower neurotransmission levels, reducing arousal or stimulation in the brain
Two DSM-5 drug classes included: Alcohol-Related Disorders and Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
Reasons for grouping together:
- Both alcohol and sedative, hypnotic, and anxiolytic medications are brain depressants, resulting in behavioral sedation
- Both act on the same cell receptors in the brain
- Cross-tolerance between alcohol and sedative, hypnotic, and anxiolytic medications (e.g., tolerance to alcohol also applies to these medications)
DSM-5 diagnostic criteria for Alcohol Intoxication and Sedative, Hypnotic, or Anxiolytic Intoxication, as well as Alcohol Withdrawal and Sedative, Hypnotic, or Anxiolytic Withdrawal, are nearly identical.

16.1 Alcohol-Related Disorders

Alcohol-Related Disorders:

Prevalence and Impact:

Most frequently used intoxicating substance in many cultures
Affects nearly every organ system, especially gastrointestinal, cardiovascular, and nervous systems
Increased risk of suicide during severe intoxication
Prevalence in the US: 4.6% among 12-17 year olds, 8.5% among adults (highest in 18-29 age group)
Variations across race/ethnic subgroups
Higher prevalence among Native Americans and Alaska Natives (12.1%) than whites (8.9%)
Lower prevalence in Asian Americans and Pacific Islanders (4.5%)
Greater impact on males but females more vulnerable to physical consequences

Characteristics of Alcohol Use Disorder:

Periods of remission and relapse
First episode often occurs during mid-teens
Impaired control over alcohol use
- Setting drinking limits that are exceeded
- Unsuccessful efforts to cut back or stop drinking
- Drinking throughout the day
- Continuing to drink despite negative consequences
- Developing tolerance
Negative social and occupational consequences, including job loss
Memory lapses and potential for dangerous behavior
Onset of withdrawal symptoms may not be apparent with changes in alcohol consumption.

Joe College

Joseph Schiavone's Case:

Joseph, a college freshman, becomes drunk for the first time after drinking beer with his fraternity brothers
He displays signs of alcohol intoxication: argumentative, impaired judgment, mood lability, physiological signs (incoordination and unsteady gait)
No prior history of aggressive or disruptive behavior
Diagnosis: Alcohol Intoxication (DSM-5, p. 497)

The Reporter's Case:

Heavier drinker for 10 years with sudden increase in drinking and withdrawal symptoms
Symptoms of alcohol withdrawal: tremors, nausea, vomiting, visual hallucinations
Intact reality testing and orientation
Diagnosis: Alcohol Withdrawal (DSM-5, p. 499)
Specifier With Perceptual Disturbances indicated due to presence of hallucinations
Pattern of drinking meets criteria for Mild Alcohol Use Disorder
Tolerance and withdrawal symptoms present.

16.2 Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

Sedative-, Hypnotic- or Anxiolytic-Related Disorders

Class Description:

Wide range of medications prescribed for calming down, aiding sleep, and reducing anxiety (sedative, hypnotic, anxiolytic)
Includes benzodiazepines and benzodiazepine-like medications (e.g., diazepam, lorazepam, clonazepam, alprazolam, zolpidem, zaleplon)
Some historical uses: carbamates (meprobamate), barbiturates (secobarbital), and barbiturate-like sleep aids (methaqualone)
Available by prescription and illegally
High liability to cause addiction or death from overdose compared to modern medications

Disorders:

Sedative, Hypnotic, or Anxiolytic Use Disorder
- Onset in teens or 20s
- Escalation in use leading to problems and diagnosis criteria
- Intermittent social use evolving into daily use and high tolerance
- Initial prescription for anxiety treatment may lead to substance-seeking behavior
- Justified continued use on basis of original symptoms
- High levels of tolerance, withdrawal (including seizures and delirium) possible

Prevalence:

12-month prevalence among 12-17 year olds: 0.3% (twice as high in females as males)
Adults age 18+: 0.2% (slightly higher rate in males than females).

August Days

August Days Case Study:

Background:

Ms. Dudek is a 55-year-old divorced schoolteacher who signed herself out of a psychiatric unit against medical advice to be detoxified from benzodiazepine (diazepam) drug.
She had a 5-year history of mouth pain, diagnosed as trigeminal neuralgia or TMJ dysfunction.
Ms. Dudek had increased her diazepam dosage to 90 mg/day despite experiencing shakiness, weakness, difficulty sleeping, and anxiety.
She was absent from work due to feeling hungover or exhausted in the morning.
Attempted treatments with carbamazepine, amitriptyline, and imipramine resulted in short-term relief but also side effects.
Her ex-husband's sudden death worsened her pain and anxiety.

Intervention:

Ms. Dudek called Dr. Sharkey for help as she had exhausted her diazepam supply and could not reduce the dosage further.
She reported withdrawal symptoms, such as rapid heartbeat, sweating, shaking hands, nausea, anxiety, and insomnia.

Diagnosis:

Diazepam Use Disorder: Tolerance, inability to reduce use, dependence, and withdrawal symptoms (DSM-5).
Diazepam Withdrawal Syndrome: Rapid heartbeat, sweating, weakness, shaking hands, nausea, anxiety, insomnia.

Considerations:

Ms. Dudek's diazepam use was not under medical supervision.
She had increased the dose on her own and attempted to obtain more than prescribed.
Possible justification for a temporary prescription of diazepam to prevent a full-blown withdrawal syndrome.
Unclear if Ms. Dudek has an underlying Anxiety Disorder or if her symptoms were solely related to diazepam use.

16.3 Stimulant-Related Disorders

Stimulant-Related Disorders

Types of Stimulants:

Amphetamines (e.g., dextroamphetamine, methamphetamine)
Other stimulants with similar effects (e.g., methylphenidate)
Cocaine in various forms (powder, freebase, crack)

Use and Abuse:

Prescribed for treatment of obesity, ADHD, and narcolepsy, sometimes diverted illegally
Instant feeling of well-being, confidence, euphoria upon use
Dramatic behavioral changes with Stimulant Use Disorder:
- Chaotic behavior
- Social isolation
- Aggressive behavior
- Sexual dysfunction
Tolerance and withdrawal symptoms (e.g., excessive sleepiness, increased appetite, dysphoria)
Chronic or episodic use, with binges and brief abstinence periods
High-dose use: anxiety resembling Panic Disorder or Generalized Anxiety Disorder, paranoid ideation, psychotic episodes
Depressive symptoms during withdrawal resolving within a week

Prevalence:

12-month prevalence of Amphetamine-Type Use Disorder: 0.2% in both 12-17 year olds and adults 18+
12-month prevalence of Cocaine Use Disorder: 0.2% in 12-17 year olds, 0.3% in adults 18+

Societal Impact:

Occurs across all levels of society
More common among individuals ages 12-25 years than 26 and older
Some individuals use to control weight or improve school/work performance

Cocaine Problem

Cocaine Problem: Al Santini's Case

Background:

39-year-old restaurant owner referred for cocaine problem evaluation
Marital issues leading to physical violence, affecting family life and children's behavior
Wife insists on treatment after failed attempts at dealing with marital problems
Previous denial of having a problem, later agrees to seek professional help

History:

First tried cocaine 5 years ago, enjoyed euphoric feeling but no unpleasant side effects
Infrequent use for nearly 3 years, rarely purchased own supplies
Escalation to current level of usage: 3-5 days a week, 1-2 grams weekly
Initial denial of addiction, but acknowledges impairment in work and family life

Significant Changes:

Financial success leading to access to large sums of cash
Growing business pressures causing entitlement and relief through cocaine use

Symptoms:

Inability to avoid using cocaine once at work
Occasional usage on weekday evenings or during weekends at home
Denies current use of other illicit drugs but takes diazepam or drinks beer instead
History of marijuana use in college, infrequent and did not enjoy it
No history of emotional problems except marriage counseling

Diagnosis:

Severely addicted to cocaine based on DSM-5 criteria: impaired control over substance use, continuation despite adverse consequences.

CAFFEINE AND TOBACCO (NONCONTROLLED STIMULANTS)

Caffeine and Tobacco (Noncontrolled Stimulants)

Caffeine-Related Disorders:

Caffeine is the most widely consumed psychoactive substance, available in various sources
85% of adults and children in the US regularly consume caffeine, with an average of 280 mg/day
Caffeine Use Disorder not included in DSM-5 due to lack of clinical significance and prevalence data
Caffeine Intoxication:
- Symptoms at doses as low as 200 mg: restlessness, nervousness, excitement, insomnia, flushed face, sweating, gastrointestinal complaints
- At higher levels (1,000+ mg): muscle twitching, rambling thought/speech, irregular heartbeat, periods of inexhaustibility, physical restlessness
- Symptoms may cause clinically significant distress or impairment
Caffeine Withdrawal:
- Develops after abrupt cessation of prolonged daily caffeine ingestion
- Headache is the hallmark feature
- Other symptoms: fatigue, depression/irritability, difficulty concentrating, flu-like symptoms (nausea, vomiting, muscle pain)
- Symptoms may occur during medical procedures, religious rituals, or missed doses
- Should be considered worthy of diagnosis if causing significant distress/impairment

Case Example: "Coffee Machine":

Eliot Evans, a 41-year-old attorney with fatigue, loss of motivation, sleepiness, headaches, nausea, and other symptoms
Symptoms occur mostly on weekends when he stops drinking coffee
Psychiatrist diagnosed Caffeine Withdrawal based on the relationship between cessation of weekend coffee and symptom onset
Evans tried to decrease daily coffee intake but could not function without his usual dose

16.5 Tobacco-Related Disorders

Tobacco Use Disorder

Nicotine:

Primary psychoactive substance in tobacco products
Cigarettes are most commonly used tobacco product (90% of use)

Prevalence of Tobacco Use Disorder:

Approximately 50% of current daily smokers have Tobacco Use Disorder
Uncommon among individuals who do not use tobacco daily or nicotine medications

Indications of Tobacco Use Disorder:

Smoking within 30 minutes of waking
Daily smoking
Larger number of cigarettes per day
Waking at night to smoke

Withdrawal from Tobacco Use:

Can impair ability to stop tobacco use
Symptoms due to nicotine deprivation
More intense among cigarette/smokeless tobacco users than nicotine medications

Tobacco Withdrawal:

Common among daily tobacco users who stop or reduce use
Can also occur in nondaily users
Approximately 50% of tobacco users who quit for 2 days experience withdrawal symptoms
Most commonly endorsed symptoms: anxiety, irritability, difficulty concentrating
Least commonly endorsed symptoms: depression, insomnia

Nicotine Replacement Therapy:

Used to help smokers stop smoking by reducing withdrawal symptoms
Example: clonidine, a medication used for high blood pressure, was used by "Junkie" Stuart Havel

Dependence on Nicotine:

"Junkie" referred to himself as a "junkie" because he recognized his dependence on nicotine
Smoked despite knowledge of physical problems
Attempted to avoid withdrawal symptoms with drugs like clonidine or nicotine patch

16.6 Cannabis-Related Disorders

Cannabis-Related Disorders

DSM-5 Definition: Cannabis refers to all forms of cannabis-like substances, including synthetic cannabinoid compounds. Synthetic oral formulations of THC are available by prescription for medical indications like nausea and vomiting caused by chemotherapy. Other synthetic cannabinoid compounds have been manufactured for nonmedical use in the form of plant material sprayed with a cannabinoid formulation (e.g., K2, Spice).

Forms of Cannabis:

Smoked or ingested orally
Vaporized: heats plant material to release psychoactive cannabinoids for inhalation

Cannabis Use Disorder and Cannabis-Induced Disorders:

Problems associated with substances derived from the cannabis plant and chemically similar synthetic compounds
Commonly smoked but sometimes ingested orally
Onset of intoxication: minutes if smoked vs. hours for oral ingestion
Regular use may contribute to coping with mood, sleep, pain, or other problems
Frequent use can cause recurrent problems related to family, school, work, etc.
Occasional use without ill effects also possible

Concurrent Substance Use Disorders:

Cannabis Use Disorder frequently occurs concurrently with other substance use disorders (alcohol, cocaine, opioid, tobacco)

Cannabis Withdrawal Syndrome:

Abrupt cessation of daily or near-daily cannabis use can result in symptoms like: irritability, anger or aggression, anxiety, depressed mood, restlessness, difficulty sleeping, and decreased appetite or weight loss.

Prevalence of Cannabis Use Disorder:

12-month prevalence among 12-17 years olds: approximately 3.4%
Prevalence among adults aged 18+: 1.5%
Highest rates among 18-29 year olds (4.4%) and lowest in those over 65 (0.01%)

Freaking Out

Mrs. Wolff's Experience with Marijuana (Cannabis)

Physical Symptoms:

Dry mouth
Increased heart rate

Psychological Symptoms:

Extreme anxiety
Paranoid ideation:
- Belief the marijuana was poisoned
- Concern neighbors would not let husband call doctor

Diagnosis:

Cannabis Intoxication (DSM-5, p. 516)
- Maladaptive reaction to cannabis use
- Extreme distress
Potential for Cannabis-Induced Psychotic Disorder (DSM-5, p. 110)
- Delusions
- Paranoid thinking did not reach delusional level
  - Reassurance from doctor
  - Realistic concern about neighbors and marijuana legality

Fidgety and Grumpy

Dorothy Calkins's Case

Background:

Dorothy, 24-year-old waitress
Anxiety problems for years, self-treated with cannabis
New symptoms of depression: anxiety, crying spells, poor sleep, weight loss, mild abdomen pain, headaches
Decided to stop cannabis use due to new job requirements and drug testing

Symptoms:

"Grumpy" behavior and fights with boyfriend
"Fidgety" and left work early due to poor sleep and wild dreams
Improvement in some symptoms but still experiencing anxiety
No changes in moderate alcohol or caffeine use, occasional tobacco use

Diagnosis:

Long-standing anxiety disorder that has worsened
Symptoms may be related to cannabis withdrawal syndrome
Lack of awareness due to:
- Not widely known that daily cannabis use can lead to clinically significant withdrawal symptoms
- Perceived marijuana as successfully treating anxiety, leading to the return of symptoms after cessation appearing as part of a withdrawal

Cannabis Withdrawal Syndrome:

Only introduced in DSM-5 in 2013
Symptoms can include irritability, anger, depression, anxiety, loss of appetite, vivid dreams, restlessness, and physical symptoms like sweating, tremors, and nausea. (Source: DSM-5, p. 517)

HALLUCINOGENS

Phencyclidine-Related Disorders

Hallucinogens:

Group of substances that produce similar alterations in perception, mood, and cognition
Includes PCP and related substances (e.g., ketamine, cyclohexamine, dizocilpine)
Lack a well-defined withdrawal syndrome in humans

Phencyclidine (PCP) Intoxication:

Characterized by disorientation, confusion, hallucinations or delusions, catatonic-like syndrome, and coma
Primary effects last for only a few hours, but can persist for weeks in vulnerable individuals, precipitating a persistent psychotic episode

Prevalence of Phencyclidine Use Disorder:

Approximately 2.5% of the population has ever used phencyclidine

Case Study: "Peaceable Man" Leo Boyer:

20-year-old man brought to the hospital, trussed in ropes by his brothers
Seventh hospitalization in 2 years for similar behavior
Exhibited agitated, violent, and disorganized behavior, slurred speech, and ataxia
Denied PCP use, but blood and urine tests were positive
Previously normal, with above-average grades, part-time job, girlfriend, and outgoing personality
First episode of emotional disturbance was sudden onset and recovered quickly
Subsequent episodes became less encouraging, with more frequent hospitalizations
Frequently intoxicated, spends time recovering from PCP use, continues to use despite trouble
Diagnosis: Phencyclidine Intoxication and Use Disorder

16.8 Other Hallucinogen-Related Disorders

Other Hallucinogen-Related Disorders

Hallucinogens:

Phenylalkylamines (e.g., mescaline) and MDMA
Indole-amines (e.g., psilocybin, DMT)
Ergolines (e.g., LSD, morning glory seeds)
Cannabis and THC are not considered hallucinogens in DSM-5 due to differences in effects

Duration of Effects:

Some hallucinogens have extended duration (LSD, MDMA)
Others are short-acting (DMT)
MDMA has distinctive effects from both its hallucinogenic and stimulant properties

Other Hallucinogen Use Disorder:

Rare, with 12-month prevalence estimated at 0.5% for 12-17 year olds and 0.1% for adults
Symptoms may include anxiety, depression, ideas of reference, fear of losing one's mind, paranoid ideation, impaired judgment

Hallucinogen Persisting Perception Disorder:

Condition where perceptual disturbances persist after sobriety
Primarily occurs after LSD use, but not strongly correlated with frequency of use
Prevalence estimated at approximately 4% among hallucinogen users

Case Study: "A Man Who Saw the Air"

21-year-old undergraduate presented with visual disturbances (white pinpoint specks, false perception of movement, halos, etc.) after LSD use
Symptoms persisted long after cessation of use, causing marked distress and impairment

16.9 Opioid-Related Disorders

Opioids:

Prescribed as analgesics, anesthetics, antidiarrheal agents, or cough suppressants
Includes natural opioids (morphine), semisynthetics (heroin), synthetics with morphine-like action (codeine, hydromorphone, methadone, oxycodone, meperidine, fentanyl)
Medications like pentazocine and buprenorphine included due to agonist and antagonist effects

Opioid Use Disorder:

Signs and symptoms: compulsive self-administration of opioids without legitimate medical purpose or for recreational purposes
Obtained illegally or through multiple prescriptions/physicians
Tolerance leading to increased doses, dependence, and withdrawal on discontinuation

Case Study: Scott LaGrange

42-year-old executive referred for psychiatric consultation after being caught with large quantities of codeine-containing cough medicine in the hospital
Heavy cigarette smoker with chronic hacking cough
Previously prescribed codeine for incisional pain 5 years ago and increased usage over time
Spending significant time obtaining supplies, unsuccessful efforts to stop use, tolerance, and use to avoid withdrawal symptoms all indicate Opioid Use Disorder (DSM-5).

INHALANTS

Inhalant-Related Disorders and Other Substance Use Disorders

Two DSM-IV-5 drug classes: Inhalant-Related Disorders, Other Substance-Related Disorders
Inhalant-Related Disorders: use of volatile hydrocarbons from glues, fuels, paints, etc.
- Toluene, benzene, acetone, tetrachloroethylene, methanol involvement
- Impairs neurobehavioral function and causes neurological, gastrointestinal, cardiovascular, pulmonary problems
- Inhalant Intoxication: develops during or immediately after inhalation of a volatile hydrocarbon substance
  - Clears within minutes to hours after exposure ends
  - Prevalence: 0.4% among 12-17 years old, 0.1% among 18-29 years old, 0.02% among all adults
  - Mostly affects males
- Characteristic symptoms: blurry vision, double vision, slurred speech, unsteady gait, depressed reflexes, tremors, muscle weakness, irregular pupils, red rash around nose and mouth
Other Substance Use Disorders: nitrous oxide or "poppers" use, anabolic steroids, nonsteroidal anti-inflammatory drugs, cortisol, antiparkinsonian medications, antihistamines, betel nut, kava, cathinones (khat plant agents and synthetic derivatives)
- Produce stimulant effects, sedation, incoordination, weight loss, mild hepatitis, lung abnormalities
Examples of specific substances: Danny Bridges' case
- Intoxicated from volatile inhalants like gasoline, glue, paint or paint thinner
- Symptoms: blurred vision, double vision, slurred speech, unsteady gait, lethargy, depressed reflexes, tremors, muscle weakness.

16.11 Gambling Disorder

Gambling Disorder

Definition:

Gambling involves risking something of value for greater gain
Disrupts personal, family, academic or occupational pursuits for some individuals
Preoccupation with gambling: reliving past experiences, planning next venture
Tolerance-like picture: increasing bets for same thrill
Continued gambling despite efforts to control

Symptoms:

Restless or irritable when trying to cut back
Escaping from problems or relieving dysphoric mood through gambling
Chasing losses, urgent need to gamble
Lying to conceal time and money spent on gambling
Jeopardizing relationships, job opportunities due to gambling
Engaging in "bailout" behavior for financial situations caused by gambling

Prevalence:

Past-year prevalence rate: 0.2%-0.3%
Lifetime prevalence rate: 0.4%-1.0% (higher for males)

Case Study: Steven Dawson

48-year-old male attorney
Interviewed while detained for embezzlement
Deeply humiliated and remorseful about gambling behavior
Lost relationship with wife, alienated friends
Borrowed from loan sharks to increase bets and pay off debts
Urge to gamble despite realizing problems stemmed from it.

Impact of Gambling:

Arrested for embezzlement and defaulting on debts
Destroyed relationships, lost job due to gambling
Relied on others to support gambling habit
Preoccupation with gambling led to antisocial behavior (borrowing, deceit) but did not meet criteria for Antisocial Personality Disorder.

CHARTER 17 Neurocognitive Disorders

Neurocognitive Disorders (NCDs)

Characteristics:

Acquired deficits in cognitive functioning
Decline from previously attained level
Cognitive domains affected: attention, executive function, learning and memory, language, perceptual-motor, social cognition

Complex Attention:

Difficulty sustaining attention
Inability to divide or focus on multiple tasks
Slow cognition due to attentional problems

Executive Function:

Planning and decision making difficulties
Problems with working memory
trouble utilizing feedback/error information
Mental flexibility issues

Learning and Memory:

Immediate memory deficits
Recent memory issues (free or cued recall)
Very long-term memory problems (semantic, autobiographical, procedural)

Language:

Expressive language difficulties: naming objects, fluency, grammar
Receptive language challenges: understanding speech, figurative language

Perceptual-Motor:

Visual perception issues: face recognition, object identification
Visuoconstructional problems: block assembly, drawing
Agnosia and apraxia symptoms: difficulty recognizing familiar objects or performing learned movements

Social Cognition:

Problems with emotion recognition in others
Lack of consideration for people's thoughts, desires, intentions

Neurocognitive Syndromes:

Delirium: Acute onset, fluctuating attention and awareness disturbance
Major Neurocognitive Disorder: Severe cognitive decline interfering with everyday independence
Mild Neurocognitive Disorder: Modest cognitive decline not significantly impairing daily activities

Diagnosis:

Determine the presence of a neurocognitive syndrome (Delirium, Major or Mild) based on symptom pattern and course for Delirium, severity for others.
Identify the etiology: medical condition, substance/medication use, or direct effects.
Combine syndrome name with its etiology to determine DSM-5 diagnosis (e.g., Delirium Due to Metabolic Disturbances).

17.1 Delirium

Delirium Syndrome

Characteristics:

Disturbance of attention and awareness (sometimes called "clouding of consciousness")
Develops over a short period of time (hours to days)
Fluctuates in severity throughout the day, often worsening at night
Reduced ability to direct, focus, sustain, and shift attention
Disorientation: to self, environment, time, or people
Impairments in memory and learning, language abilities, and perception (visual)
Hallucinations or misinterpretations of stimuli

Causes:

Underlying medical conditions
Medication or substance use
Combinations of the above

Common Causes:

Medication use, particularly anticholinergics
Alcohol or psychoactive drug intoxication/withdrawal
Dehydration
Infections (pneumonia, septicemia)
Strokes
Head trauma
Endocrine disorders (Cushing's syndrome, hyperthyroidism)
Metabolic abnormalities (fluid and electrolyte, liver or kidney failure)

Diagnosis:

DSM-5 includes multiple diagnostic types: Substance Intoxication Delirium, Substance Withdrawal Delirium, Medication-Induced Delirium, Delirium Due to Another Medical Condition, and Delirium Due to Multiple Etiologies.
Treatment requires correcting the underlying cause.

Occurrence:

Can occur at any age but more common among the elderly
Hospital admission prevalence: 14%-24%
Incidence during hospitalization: 6%-56% in general populations
Common after surgery (15%-53%) and among nursing home residents, intensive care unit patients (70%-87%)
In younger people, usually due to drug use or life-threatening medical condition.

Traction

Mr. Hernandez's Medical History

Background:

Diego Hernandez, 32-year-old carpenter from Nevada
Sustained multiple injuries in a motor vehicle accident
Lost consciousness and had amnesia after the accident
Alert upon admission, but complained of severe back pain

Treatment:

Treated with narcotic pain killer (meperidine) and sleeping pill (zolpidem)
Diagnosed with Alcohol Withdrawal and given benzodiazepine (diazepam)
Experienced symptoms of anxiety, agitation, and constant scratching
Developed fever, which led to further investigation

Diagnostic Findings:

Negative blood cultures, urinalysis, and chest X-ray
Given antihistamine for itching
Became disoriented and delirious, with confusion about time and place
Underwent surgery for a fractured left acetabulum
Post-surgery, still disoriented and picking at things in the air
Elevated temperature with no documented source of infection

Medication Regimen:

Narcotic painkillers (oxycodone and meperidine)
Benzodiazepine (diazepam) for alcohol withdrawal
Muscle relaxant (diazepam)
Hypnotic (zolpidem)
Antihistamine (hydroxyzine)
Acetaminophen

Progression of Delirium:

Disoriented and delirious for several weeks
Frequently dismantled traction apparatus at night, then denied it the next day
Experienced severe pain and argued with doctors to give more medication
Observed playing with fecal matter and acting strangely
Asked for a "game plan" to stop the behavior

Conclusion:

Diagnosis: Delirium Due to Multiple Etiologies (DSM-5, p. 597)
Symptoms resolved once medical problems were addressed and medication was reduced.

Thunderbird

Patient Information:

Tremaine Graves
43-year-old divorced construction worker
Heavy daily alcohol user for over 5 years: 1 bottle of wine or more
Consistently drunk for several hours every day since divorce
Unstable employment history due to alcohol use, missed work, and frequent blackouts
Recently ran out of money and wine, resorted to begging on the street
Poorly nourished, eating one meal a day, relied heavily on wine for nutrition
Sudden cessation of alcohol use led to severe withdrawal symptoms

Symptoms:

Apprehension and chatty, superficial warmth
Rambling speech
Confused and disoriented
Hand tremors at rest
Disorientation for time and place
Delusions: fear of impending holocaust
Perceptual disturbances: seeing "bugs" on bedsheets, hallucinations of car crashes
Inability to test memory or do calculations
Disturbed awareness, loss of track during interview

Diagnosis:

Alcohol Withdrawal Delirium (DSM-5, p. 597)
Symptoms include disturbance in attention and awareness, cognitive deficits, disorganized thinking, perceptual disturbances, confusion.
Autonomic hyperactivity: hand tremors indicate high risk for respiratory failure or cardiac arrhythmias.

Additional Diagnosis:

Alcohol Use Disorder (DSM-5, p. 490)
Heavy daily alcohol use for over 5 years
Poorly nourished and malnourished
Lost jobs due to alcohol use
Inability to control alcohol intake despite negative consequences.

17.2 Major Neurocognitive Disorder

Major Neurocognitive Disorder (MND)

Characterized by acquired cognitive decline in one or more domains: attention, executive function, learning and memory, language, perceptual-motor, social cognition
Formerly known as "dementia" to reduce stigma
Diagnosis requires evidence of cognitive decline from multiple sources (individual complaints, observable behaviors, mental status examination) and impairment on cognitive testing
Severe enough to interfere with independent functioning
Additional features may include: psychotic symptoms (paranoia, delusions, hallucinations), mood disturbances, agitation, sleep problems, apathy, behavioral symptoms
Diagnosis depends on etiology (Alzheimer's disease, frontotemporal lobar degeneration, Lewy body disease, vascular disease, traumatic brain injury, Parkinson's disease, HIV infection, substance use)
Prevalence estimates: 1%-2% at age 65 and up to 30% by age 85.

Symptoms of Major Neurocognitive Disorder:

Cognitive decline in various domains
Evidence from multiple sources (individual complaints, observable behaviors, mental status examination)
Impairment on cognitive testing, two or more standard deviations below norms
Severe enough to interfere with independent functioning
Additional features: psychotic symptoms, mood disturbances, agitation, sleep problems, apathy, behavioral symptoms (With Behavioral Disturbance specifier)

Etiology of Major Neurocognitive Disorder:

Alzheimer's disease (60%-70%)
Frontotemporal lobar degeneration
Lewy body disease
Vascular disease
Traumatic brain injury
Parkinson's disease
HIV infection
Substance use (inhalant abuse, chronic heavy alcohol or sedative use)
Multiple etiologies.

The Hiker

Mr. Walling's Case

Background:

Age 61, high school science department head, experienced hiker and camper
Became fearful during mountain trek at age 61
Gradual loss of interest in hobbies and reading
Intellectual deterioration over next few months
Difficulty with computations, errands, and remembering familiar routes
Abrupt retirement from work without discussing plans with wife

Symptoms:

Memory impairment (short term and long term)
Abstract thinking impairment
Language problems
Personality change (stubborn, querulous)

Diagnosis:

Major Neurocognitive Disorder
Alzheimer's Disease (likely)

Characteristics of the Disorder:

Gradual decline in cognition with no extended plateaus
Clear evidence of decline in memory and learning
Impairment in at least one other cognitive domain
Absence of evidence suggesting other neurodegenerative or cerebrovascular diseases, neurological, mental, or systemic conditions contributing to cognitive decline

Diagnostics:

No objective laboratory tests for definitive diagnosis
Diagnosis based on clinical grounds and pattern of symptoms

Mr. Walling's Symptoms:

Memory impairment (both short term and long term)
Impairment in several other cognitive domains
Onset was insidious with a steady course of deterioration over the past 6 years

Additional Findings:

Normal neurological examination
Routine laboratory tests negative
No evidence of vascular disease on CT scan
Marked cortical atrophy (CT scan)

Conclusion:

Major Neurocognitive Disorder Due to Alzheimer’s Disease (DSM-5, p. 611).

Certified Public Accountant

Mr. Rosen's Case:

Background:

Age: 69 years old
Self-employed tax accountant
Noticed memory slipping, concentration issues interfering with work
Recent changes in tax laws difficult to learn
Withdrawn and reluctant to initiate activities
History of depression treatment since 20s
Previous treatments: Antidepressant medications, electroconvulsive therapy (ECT)
Developed tremor in left hand and shuffling gait 2 years earlier, but no confirmation of Parkinson's disease

Evaluation Findings:

Neurological examination revealed hesitant and unclear speech (dysarthric), normal cranial nerve function, increased muscle tone, slow movement of hands, intermittent tremor in left arm
Diagnosis: Idiopathic Parkinson's disease
Treatment: Low dose of carbidopa-levodopa medication
Neuropsychological examination showed average intelligence (WAIS full-scale IQ 104), poor memory, difficulty with naming and constructional abilities
Additional evaluations: MRI - generalized atrophy; EEG - background slowing

Progression of the Disease:

Motor function improved with Parkinson's medication but memory worsened
Described difficulty in decision making, memory impairment, word-finding problems
Increasing difficulty in understanding speech and experiencing freezing episodes
Fell frequently due to foot "sticking" to the floor (freezing episodes)
Worsening of Parkinson's disease symptoms

Diagnosis:

Major Neurocognitive Disorder Due to Parkinson's Disease (DSM-5, p. 636)

Prevalence and Co-morbidities:

Prevalence of Parkinson's disease in the U.S.: 0.5% between ages 65 and 69 to 3% at age 85 years and older
More common in males than females
Up to 75% of individuals with Parkinson's disease will develop a Major Neurocognitive Disorder (DSM-5, p. 637)

Chief Petty Officer

Chief Petty Officer's Case:

Medical student presentation at rounds: 56-year-old retired chief petty officer, Will Genardo
Background:
- Long-time heavy consumer of alcoholic beverages
- Divorced, drinking became excessively heavy
- Belligerent behavior, assaulted family members
- Multiple hospitalizations for alcohol withdrawal and disturbing behavior
- Lived in nursing home due to inability to care for himself, later admitted to hospital
Presenting Symptoms:
- Somewhat peevish and inattentive during examination
- Consciousness not clouded, no hallucinations
- Couldn't retain names of five objects after distraction
- Memory loss for recent events but recalled youth and young manhood
- No recollection of the 2003 U.S. invasion of Iraq
- Language normal, struggled with simple calculations and interpreting proverbs
- Neurological examinations showed diminished ankle jerk reflexes, mild unsteadiness of gait
Diagnosis:
- Major Neurocognitive Disorder
- Absence of history of trauma
- Failure to reveal etiology from laboratory tests
- Prolonged heavy drinking most likely cause: Alcohol-Induced Major Neurocognitive Disorder (DSM-5, p. 627)
Differential Diagnosis:
- Search for specific causes: head trauma, brain tumor
- Absence of history of trauma rules out Major Neurocognitive Disorder Due to Alzheimer’s Disease (stable course over many years).

17.3 Mild Neurocognitive Disorder

Mild Neurocognitive Disorder (MNCD)

Definition:

Gradual decline in mental abilities greater than normal aging
Modest cognitive decline on neuropsychological testing
Does not interfere with independence in everyday activities
May require greater effort, use of compensatory strategies, or accommodations

Characteristics:

Greater forgetfulness than typical for age
Difficulty with directions and word recall
Not severe enough to impair daily functioning
Can't be attributed to other conditions (DSM-5, p. 605)

Distinguishing Features:

Less severe than Major Neurocognitive Disorder
Performance on neuropsychological testing between 3rd and 16th percentiles
No significant interference with independence in everyday activities

Prevalence:

Prevalence estimates vary from 2% to 10% at age 65 and 5% to 25% by age 85.

Etiology:

Caused by various conditions and substances (DSM-5, p. 605)

Backstage With Rosie!

Background:

Rosie Shapiro, a 70-year-old New Yorker, brought by her niece to an evaluation center due to concerns about her wellbeing
Niece noticed that her aunt's food supply was low and unopened mail was piling up
Aunt had been living alone since husband's death five years ago, with no children of her own

Assessment:

Psychiatrist found that Mrs. Shapiro had a rich past in the theater (husband managed productions, she designed wardrobes)
Struggled to recall current facts such as President's name or common events
Performed poorly on memory tests, but showed no signs of other cognitive impairments like agnosia, apraxia, aphasia, or constructional difficulties
Forgetfulness was becoming a problem for her
CT scan revealed beginning signs of cortical atrophy

Diagnosis:

Mild Neurocognitive Disorder due to possible Alzheimer's disease
Gradual decline in cognitive functioning primarily affecting memory
No evidence of other neurological or systemic conditions contributing to cognitive decline

Future Prospects:

Most individuals with Mild Neurocognitive Disorder do progress to Major Neurocognitive Disorder Due to Alzheimer’s Disease, but some remain stable or improve.
Longitudinal studies suggest that 10%-15% of people convert each year.

CHAPTER 18 Personality Disorders

Personality Disorders

Among most impairing mental disorders
Difficult to diagnose
Challenging to treat

Characteristics of Personality Disorders:

Significant problems in self-appraisal and self-regulation
Impaired interpersonal relationships
Up to 50% of clinical patients have a Personality Disorder
Co-occur with other mental disorders

DSM-5 Models for Personality Disorders:

Main Section (Section I): Defined as an enduring pattern of deviant behavior, thought, and emotion that leads to distress or impairment. Manifested in two or more areas: cognition, affectivity, interpersonal functioning, impulse control.
Alternative Model (Section III): Characterized by impairments in personality functioning and pathological personality traits. Impairments in personality functioning identify core features of personality psychopathology. Pathological personality traits manifest in presentations of personality pathology. Personality Disorders are relatively stable, with a tendency toward improvement or remission over time.

Co-occurrence of Mental Disorders:

Symptoms may vary together, leading to attempts to understand organization of psychopathology through dimensions like internalizing, externalizing, and thought disorder spectra
Disorders within these broad domains share risk factors, cognitive/emotional processing abnormalities, and respond to similar treatments

DSM-5 Alternative Model of Personality Disorders: Describes personality pathology in terms of five broad trait domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, Psychoticism. Each domain includes specific facets as defined below.

TABLE 18-1. Definitions of DSM-5 Personali trait facets ORTRONICS lity Disorder (Alternative Model) Domains and facets Definition Negative Affectivit

DSM-5 Personality Disorder (Alternative Model) Domains and Facets

Negative Affectivity:

Emotional lability: Instability of emotional experiences and moods
Anxiousness: Fearful and apprehensive feelings, expecting the worst
Separation insecurity: Fears of being alone due to rejection or separation from significant others
Submissiveness: Adapting behavior to others' interests at the expense of own
Hostility: Persistent anger, irritability, and vengeful behavior
Perseveration: Continued behavior despite failure or lack of reason
Depressivity: Feelings of being down, hopeless, with deficits in pleasure and self-worth

Detachment:

Withdrawal: Preference for being alone, reticence in social situations
Intimacy avoidance: Avoidance of close relationships and intimate sexual relationships
Anhedonia: Lack of enjoyment from life's experiences, deficits in pleasure and interest

Antagonism:

Manipulativeness: Use of subterfuge to influence or control others
Dishonesty and fraudulence: Misrepresentation of self, embellishment or fabrication
Grandiosity: Belief of superiority and entitlement
Attention seeking: Engaging in behavior to make oneself the focus of attention

Disinhibition:

Impulsivity: Difficulty establishing and following plans, acting on spur of the moment
Risk-taking: Engagement in dangerous, self-damaging activities without regard for consequences
Psychoticism: Unusual beliefs, experiences, and behaviors

Cognitive and Perceptual Dysregulation:

Eccentricity: Odd, unusual behavior, appearance, and speech
Cognitive thought processes and experiences: Depersonalization, derealization, dissociative experiences

Whether consideréd from the main or alternative model presented in DSM-5, Per- sonality Disorders vary in their manifestations and complexity. Some P

Personality Disorders in DSM-5

Background:

Personality Disorders vary in manifestations and complexity
Classified based on traits of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism
Some related to internalizing or externalizing disorders, others to psychotic disorders
Complexity reflected by co-occurrence with other Personality Disorders and mental disorders

Personality Disorder Clusters:

Borderline Personality Disorder: central, most clinically important (internalizing and externalizing features)
Dependent Personality Disorder: excessive need for care, fears of separation
Avoidant Personality Disorder: social inhibition, feelings of inadequacy
Obsessive-Compulsive Personality Disorder: orderliness, perfectionism
Antisocial Personality Disorder: disregard for rights of others, history of Conduct Disorder
Narcissistic Personality Disorder: grandiosity, need for admiration
Histrionic Personality Disorder: excessive emotionality and attention seeking
Schizotypal Personality Disorder: detachment from social relationships, cognitive or perceptual distortions
Schizoid Personality Disorder: restricted range of expression of emotions
Paranoid Personality Disorder: persistent distrust and suspiciousness

Other Specified Personality Disorders:

Personality disturbance that does not meet full criteria for any Personality Disorder
Symptoms characteristic of a personality disorder but do not fit into existing categories

DSM-5 Alternative Model:

Six specific Personality Disorders: Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-Compulsive, and Schizotypal
Level of Personality Functioning Scale for severity of impairment in identity, self-direction, empathy, and intimacy.

18.1 Borderline Personality Disorder Borderline Personality Disorder is defined by “a pervasive pattern of instability in interpersonal relationships

Borderline Personality Disorder (BPD)

Definition:

Pervasive pattern of instability in interpersonal relationships, self-image, and affects
Impaired capacity for attachment to others
Maladaptive behavior problems related to separation from depended-upon individuals

Characteristics:

Significant identity disturbance: unstable self-image or sense of self
Feel "empty" inside
Frantic efforts to avoid real or imagined abandonment
Unstable and intense interpersonal relationships:
- Idealization (another person can do no wrong)
- Devaluation (another person can do no right)
Affective instability or lability:
- Mood swings with dysphoria, irritability, anxiety
- Intense anger and difficulty controlling it
- Transient dissociative or paranoid reactions under stress
- Recurrent suicidal behavior, gestures, or threats
- Self-mutilating behavior
- Impulsivity: indiscriminate sex, substance abuse, reckless driving, binge eating, overspending

Diagnostic Criteria (DSM-5):

Poorly developed and unstable self-image
Instability in goals and values
Compromised ability to recognize needs and feelings of others (interpersonal hypersensitivity)
Intense and unstable close relationships
High prevalence: 1.6%-5.9% in population, up to 20% in psychiatric inpatients
Impairing effects on social relationships and work functioning

Treatment:

Appropriate treatment is necessary due to the waxing and waning course of BPD.

Empty Shell

Zoe Barnes' Background

Admitted for first psychiatric hospitalization: 23-year-old veterinary assistant
Arrived late at night, referred by a local psychiatrist
Initial statement: "I don't really need to be here"

Preceding Events

3 months before admission: Learned mother became pregnant
Began drinking heavily, ostensibly to help sleep
Involved in "one-night stands" during drinking episodes
2 weeks before admission: Experienced panicky feelings, feeling removed from her body and in a trance
Police stopped her on a bridge, fearing she was going to jump
Referred to psychiatrist and hospitalized

Appearance and Behavior at Hospitalization

Appeared as a disheveled and frail, but appealing, waif
Cooperative, coherent, and frightened
Acknowledged feelings of loneliness, inadequacy, frequent brief periods of depressed mood and anxiety since adolescence
Had fantasies of stabbing herself or a baby with a knife
Complained about being "just an empty shell that is transparent to everyone"

Family Background

Parents divorced when she was 3 years old
Lived with maternal grandmother and mother until age 6
Attended special boarding school for a year and a half, then withdrawn by mother
When 8, experienced the death of her maternal grandmother
Spent next 2 years living with various relatives, including father
At age 9, mother hospitalized with a diagnosis of Schizophrenia
Lived with aunt and uncle from age 10 through college, but had ongoing contacts with mother
Dated regularly since adolescence, but relationships ended abruptly after anger and devaluation
Manipulated efforts to keep roommates from seeing others

Work History

Worked steadily and well as a veterinary assistant since college
Quit therapy after 3 months with new boyfriend, complaining therapist "didn't really care or understand her"

Diagnosis Discussion: Empty Shell

Characteristic features of Borderline Personality Disorder: Unstable interpersonal relationships, self-image, affects, and impulse control
Relationships with men: Intense and unstable, end when she becomes angry and devalues them
Self-perception: "An 'empty shell', evidence of chronic feelings of emptiness and distorted self-image"
Affective instability: Frequent brief periods of depressed mood and anxiety since adolescence
Impulsivity: Drinking, sex, suicidal gestures or self-mutilating acts (slashing wrists)
Recent symptoms: Heavy drinking, depersonalization, anxiety, depression, suicidality
Brief auditory hallucinations suggesting Psychotic Disorder, but transient and not warranted as primary diagnosis
Depersonalization/Derealization Disorder also considered but found to be superfluous given Borderline Personality Disorder.

Disco Di

Ms. Miller's Background and History

Age 25, entered long-term treatment unit of a psychiatric hospital after serious suicide attempt
Cheerful and outgoing disposition changed drastically at age 12 to becoming demanding, sullen, and rebellious
Took up with "fast" crowd, became sexually promiscuous, abused marijuana and hallucinogens, ran away from home
Had stormy relationships with men: passion, unbearable longing, violent arguments
Craved excitement: got drunk and danced wildly in discos, left with strange men
Frequent suicide attempts (severe wrist cut, first hospitalization at age 17)

Symptoms During Outpatient Treatment

Afraid to travel without parents, depressed with suicidal preoccupations
Excessive alcohol use and diazepam abuse (up to 80 mg/day)
Eating binges followed by crash diets, obsessed with calories and food arrangement
Tantrums if mother fails to comply with rules, broke dishes, physically restrained by father
Refused to join AA or attend day program, languished at home, became more depressed and agoraphobic
Escalated diazepam use, serious suicide attempt led to 7th psychiatric hospitalization

Symptoms in Hospital and Recovery

Complained about "cruel" nurses and hated by other patients
Extremely sensitive to decreasing diazepam levels, weaned only 1 mg at a time
After 3 months off diazepam, progress was unexpectedly good: cheerful disposition, cooperative, friendly, learned secretarial skills
Developed friendship with another convalescing patient, continued therapy weekly as outpatient

Diagnoses and Discussion

Diagnosis of Major Depressive Disorder or Persistent Depressive Disorder based on depression and suicide attempt
Benzodiazepine Use Disorder due to escalating diazepam use and tolerance
Binge-Eating Disorder possible due to frequent binges
Primary disturbance is likely Borderline Personality Disorder:
- Unstable and intense interpersonal relationships, ideation, devaluation of men
- Identity disturbance (no goals), impulsive behavior (sex, substance abuse, eating)
- Recurrent suicidal behavior, affective instability, inappropriate anger, feeling of being "eaten alive" with boredom
- Features of other personality disorders: Narcissistic, Histrionic, Obsessive-Compulsive, and Dependent.

18.2 Dependent Personality Disorder

Dependent Personality Disorder (DPD)

Characteristics:

Pervasive need to be cared for
Submissive and clinging behavior
Fear of separation
Underestimate abilities and judgment
View others as more capable
Seek support from others for decisions
Feel uncomfortable disagreeing with others
Need to find someone new to depend on when a close relationship ends

Diagnosis:

Personality Disorder—Trait Specified (DSM-5, p. 770)
Moderate impairment in personality functioning
Traits: submissiveness, separation insecurity, anxiousness (Negative Affectivity)
Prevalence: around 0.5%-0.6%
More common among women than men

Development and Cultural Norms:

Developmentally appropriate in children and adolescents
Becomes less acceptable as individuals mature
Cultural and subcultural norms should be considered

Impact on Quality of Life:

Moderate impairment
Psychosocial dysfunction

Case Study: "Blood Is Thicker Than Water"

Morgan Stewart:

Single man living with mother, works as an accountant
Unhappy after breaking up with girlfriend due to disapproval from his mother
Afraid of disagreeing with mother for fear of losing support and approval
Resentment towards mother but also admires her judgment
Fear of independence and responsibility
Lack of assertiveness, teased as a child
History of dependency on others (mother, elder sisters)
Difficulty leaving home, homesickness during college
Patterns of subordinating own needs to those of his mother
Diagnosed with Dependent Personality Disorder.

18.3 Avoidant Personality Disorder

Avoidant Personality Disorder (APD)

Characteristics:

Pervasive pattern of social inhibition
Feelings of inadequacy
Hypersensitivity to negative evaluation
Poor self-image
Avoidance of occupational activities with significant interpersonal interaction due to fear of criticism and disapproval
Reticent in social life, seeking guarantees of being liked
Afraid of rejection, shame, or ridicule
Risk averse

Symptoms:

Fear of embarrassment
Reluctance to pursue goals or take personal risks
Preoccupation with and sensitivity to criticism or rejection
Reluctance to get involved with others unless certain of being liked
Lack of criticalness or ability to get angry at others, except for social or political issues

Diagnosis:

Included as a specific Personality Disorder in the Alternative DSM-5 Model (DSM-5, p. 765)
Characterized by moderate impairments in personality functioning: self-appraisal as socially inept, reluctance to pursue goals or take personal risks, preoccupation with and sensitivity to criticism or rejection, reluctance to get involved with others unless certain of being liked
Traits of anxiousness, withdrawal, anhedonia, and intimacy avoidance from the Detachment domain

Prevalence:

Estimated population prevalence of about 2.4%
Equally common in men and women

Development:

Often begins in infancy or childhood with excessive shyness and fear of strangers or novel situations
Some individuals may get increasingly withdrawn in adolescence or early adulthood when expanding their social network becomes important for development

Impairments:

Impairs functioning in both the social and occupational spheres

Case Study: Barbara Nowak

26-year-old teacher's aide seeking counseling due to feeling increasingly lonely and "lost" since her sister moved away
Only real social contacts are her sister and one high school friend
Afraid of men, characteristically cuts off potential relationships after two or three dates due to fear of rejection
Relationships with others are superficial, structured through work, civic groups, or church club
Discussion of "Sad Sister"
- Long-standing difficulty establishing relationships with others due to significant impairments in self-concept and interpersonal relationships
- Lack of criticism or ability to get angry at others, except for social or political issues
- Poor self-esteem, feeling she has little to offer others
- Reaction to sister's move is an expression of her Avoidant Personality Disorder rather than a new illness.

The Jerk

Leon Mitchell's Case Study:

Background:

45-year-old single postal employee
Evaluated at a clinic for depression
Claims of constant depression since first grade
Depression accompanied by lethargy, lack of interest/pleasure, trouble concentrating, feelings of inadequacy, pessimism, resentment
Only periods of normal mood during solo activities (listening to music or watching TV)

Early Social Experiences:

Couldn't remember feeling comfortable socially
Felt overwhelming anxiety at children's social functions
Struggled with oral classroom participation
Met new children with eyes lowered, fearing scrutiny and humiliation

Adolescence and Adulthood:

Had few playmates as a child but no best friend
Poor school grades due to oral participation expectations
Terrified of girls, never dated
College attendance was good but dropped out with slipping grades
Difficulty finding jobs due to interview anxieties
Enjoyed job at post office for minimal social contact
Refused promotions due to fear of social pressures
Lack of friends, avoided coworker invitations

Diagnosis:

Persistent Depressive Disorder (Dysthymia) with Early Onset before age 21
Social Anxiety Disorder (Social Phobia)
Avoidant Personality Disorder

Additional Information:

Gradual build-up of anxiety to a constant high level in anticipation of social situations
No psychotic symptoms or sudden anxiety/panic attacks
Symptoms overlap with Avoidant Personality Disorder
Future research needed for clarification on the relationship between Social Anxiety Disorder and Avoidant Personality Disorder.

18.4 Obsessive-Compulsive Personality Disorder

Obsessive-Compulsive Personality Disorder (OCPD)

Characteristic personality pattern: preoccupation with orderliness, perfectionism, mental and interpersonal control (DSM-5)
Extreme traits cause distress or functional impairment: neatness, punctuality, organization, conscientiousness
Individuals forget point of activities, never finish tasks due to perfectionism
Reluctant to delegate, exert control over others in relationships and work
Emotionally unemotional, difficulty expressing caring feelings towards others
Hoarding of worthless objects (DSM-5, p. 678)

Impairments in Personality Functioning: moderate level impairment

Sense of self derived from work or productivity
Difficulty completing tasks and realizing goals
Difficulty understanding ideas and feelings of others
Rigidity and stubbornness negatively affecting relationships (DSM-5, p. 768)

Traits: rigid perfectionism, perseveration (Negative Affectivity), intimacy avoidance, restricted affectivity (all Detachment)

Prevalence: common Personality Disorder with prevalence ranging from 2.1% to 7.9%

More common in men than women

Impairment in Interpersonal Functioning: significant impairment due to need for control and restricted emotional range:

Few intimate relationships or history of breakups, separations, divorces. (cultures emphasizing work and productivity may see less impairment as long as individuals are willing to work excessively)

The Workaholic

The Workaholic: Jacob Nielsen's Case Study

Background:

45-year-old lawyer seeking treatment due to marital issues at wife's insistence
Known for emotional coldness, rigidity, bullying behavior, sexual disinterest, long work hours, and frequent business trips
Agrees to consultation only to humor his wife

Problems at Work:

Hardest-driving member of a hardworking law firm
Youngest full partner in firm's history
Perfectionist with unrealistic expectations from himself and others
Constantly correcting assistants' work, unable to stay abreast of schedule
Critical of mistakes made by others
Unable to delegate responsibility
Difficulty making decisions when work expands beyond own control
Works 15-hour days to keep up
Secretaries cannot tolerate working for him due to criticism

Personality Traits:

Cold, rigid, excessively perfectionistic, preoccupied with details
Indecisive but insists others do things his way
Interpersonal relationships suffer due to excessive work devotion
Characteristic features of Obsessive-Compulsive Personality Disorder (DDM-5, p. 678)

Childhood:

Superior student, "bookworm"
Awkward and unpopular in adolescence
Competitive, high achiever
Struggles to relax on vacations, creates elaborate activity schedules for family members
Ferocious competitor, poor loser in sports.

18.5 Antisocial Personality Disorder

Antisocial Personality Disorder

Characteristics:

Pattern of socially irresponsible behaviors
Disregard for and violation of others' rights
Frequent unlawful acts
Personalities characterized by deceitfulness, impulsivity, irritability/aggression, recklessness, irresponsibility, callousness/lack of remorse
Diagnosis only for individuals age 18 and older with a history of Conduct Disorder before age 15

Traits:

Egocentrism
Absence of prosocial internal standards
Lack of concern for others' feelings or needs
Exploitation, intimidation as means of relating to others

Diagnosis:

Included in Alternative DSM-5 Model for Personality Disorders
Impairments in personality functioning at a moderate level
Pathological personality traits: Antagonism (manipulativeness, callousness, deceitfulness, hostility) and Disinhibition (irresponsibility, impulsivity, risk taking)

Prevalence:

Estimates of prevalence in the general population range from 0.2% to 3.3%
Higher prevalence among males with Alcohol Use Disorder and substance abuse clinics, prisons, and forensic settings

Course:

Chronic beginning with evidence of Conduct Disorder before age 15
Often with oppositional behavior and Attention-Deficit/Hyperactivity Disorder
Criminal behavior and manifestations may decrease by mid-40s

Case Study: Belligerent Boy

History of multiple arrests for drug charges, robbery, assault, truancy, fighting, poor school performance
Expelled from junior high school
Placed in juvenile detention center after car theft at age 14
Disruptive and threatening behavior towards parents, admitted to psychiatric hospital and signed out against medical advice
Lives as a "loner and drifter", has not worked consistently
Expresses no remorse for past behaviors or feelings about people he has harmed
Terminated from vocational training program due to fighting and poor attendance.

18.6 Narcissistic Personality Disorder

Narcissistic Personality Disorder (DP) Characteristics:

Pervasive pattern of grandiosity, need for admiration, lack of empathy (DSM-5, p. 669)
Grandiose self-image hides feelings of inferiority (modern perspective)
Vulnerable presentations: anxiety, depressivity, anxiousness, and depressivity from Negative Affectivity trait domain (DSM-5, p. 768)
Inflated or deflated self-appraisal
Excessive reference to others for self-esteem regulation
Goal setting based on gaining approval of others
Inability to recognize feelings and needs of others
Suceptibility to strong reactions towards rejections, criticisms, or defeats
Social withdrawal and a facade of self-sacrifice (hidden superiority)

Diagnostic Criteria:

Narcissistic personality traits interfere with academic achievement and relationships
Appropriate diagnosis: Narcissistic Personality Disorder (DSM-5, p. 669)
Long duration of symptoms (assumption based on no description of episodic narcissism in literature).

Narcissistic Personality Traits:

Grandiosity about importance of thesis or work
Preoccupation with fantasies of great success in career and relationships
Belief of being special and entitled to admiration
Self-centeredness and lack of empathy
Envy towards others
Quickly forming and dissolving friendships
Anger, self-doubt, and shame (vulnerable side)
Infatuation with women followed by disappointment in their intelligence or personality.

False Rumors

Bob Bailey's Case: Narcissistic Personality Disorder (NPD)

Background:

21-year-old man seeking help due to parental pressure, denies having problems
Spread false rumors about teachers and classmates
Excellent academic performance in certain areas but dismissed importance of development

Behavior:

Grandiose and insensitive (lack of empathy)
Jealous of siblings and peers
Arrogant and withdrawn in school
Loner, distanced himself from parents
Cold or insensitive behavior dismissed as unimportant
Believed others envied him
Occasional dating with no steady girlfriends
History of conflict with authorities
Spreading rumors to gain attention and admiration

Diagnostics:

Narcissistic Personality Disorder (DSM-5, p. 669)
Grandiosity and insensitivity
Jealousy
Spreading rumors about teachers and peers
Trouble with authorities
Interpersonally exploitative
Entitlement
Deceitful and manipulative behavior (false rumors)
Masked vulnerable self-concept
Signs of Antisocial Personality Disorder in severe cases.

18.7 Histrionic Personality Disorder

Histrionic Personality Disorder

Characteristics:

Pervasive pattern of excessive emotionality and attention seeking (DSM-5)
Needs to be the center of attention
Uses physical appearance and sexually seductive/provocative behavior to draw attention
Exaggerated, effusive, but labile and shallow emotions
Dramatic interpersonal style
Impressionistic speaking style
Believes relationships are closer than they actually are

Diagnosis (Alternative DSM-5 Model):

Personality Disorder—Trait Specified
Impairment in personality functioning is moderate
Domains and personality traits:
- Emotional lability (Negative Affectivity domain)
- Attention seeking and manipulativeness (Antagonism domain)

Prevalence:

Approximately 2% in community population
Slightly more common in women

Coquette Carla Peters' Case:

Initially tearful and suicidal, but became animated and dramatic during sessions
Attractively and seductively dressed, wore makeup, and revealed clothing
Dramatic storytelling, shallowness, self-indulgent behavior causing interpersonal problems
Lacks grandiosity or sense of uniqueness (precludes Narcissistic Personality Disorder)
No evidence of most Borderline Personality Disorder characteristics

18.8 Schizotypal Personality Disorder

Schizotypal Personality Disorder

Characteristics:

Cognitive or perceptual distortions: ideas of reference, bodily illusions, unusual beliefs
Eccentricities of behavior: talking to self, strange dress, odd speech
Disorder-specific impairments: confused boundaries, unrealistic goals, misinterpreting others
Traits in two domains: Psychoticism (cognitive and perceptual dysregulation), Detachment (restricted affectivity, withdrawal, suspiciousness)

Symptoms:

Depersonalization: feeling detached from reality
Derealization: world seems unreal
Magical thinking: ability to read minds, ideas of reference
Social isolation, odd speech, suspiciousness

Prevalence: 0.6% to 4.6% in community studies

Can begin in childhood or adolescence as solitary behavior, poor peer relationships, social anxiety

Prognosis: Impairing Personality Disorder with a relatively stable course over time

Strong genetic relationship to Schizophrenia but rare evolution into Psychotic Disorders

Case Study: "Clairvoyant" Ms. Carter:

32-year-old single unemployed woman with feelings of detachment and unreal world
Ability to read people's minds, social isolation, suspiciousness, odd speech
Long-standing maladaptive pattern suggesting Schizotypal Personality Disorder
Belief in clairvoyance not firmly held, likely magical thinking rather than delusion.

Wash Before Wearing

Patient: Seymour Goldstein

Referred to community mental health center for help with social skills
Lifelong pattern of social isolation, no real friends
Spends long hours worrying about angry thoughts about older brother
Previously worked as clerk in civil service, lost job due to poor attendance and low productivity
On intake interview:
- Distant and somewhat distrustful
- Describes uneventful routine life in elaborate, irrelevant detail
- Spends hours deciding between fish food brands, studying washing instructions
- Buys multiple identical items, reluctant to spend money on things he needs
- Knows bank account balance but gets anxious about checks clearing
Reluctant to reveal personal information in groups due to fear of manipulation

Diagnosis:

Prominent symptoms: absence of close friends or confidants, magical thinking, constricted affect, odd speech, social anxiety with paranoid fears
Schizotypal Personality Disorder (DSM-5): absence of close friends, eccentricities of thought and speech, social anxiety, paranoia
- Differs from Autism Spectrum Disorder: lack of awareness and emotional reciprocity, stereotyped behaviors and interests
- Differs from Schizoid Personality Disorder: presence of eccentricities of thought and speech
Obsessive-Compulsive Disorder (OCDE): concerns with fish food and jeans instructions, preoccupation with organizing finances, miserly spending
- Does not meet full criteria for OCPD due to lack of intrusive, unwanted thoughts or compulsions

18.9 Schizoid Personality Disorder

Schizoid Personality Disorder (SPD)

Characteristics:

Pervasive pattern of detachment from social relationships
Restricted range of emotional expression in interpersonal settings
Preference for solitary activities
Little interest in sexual experiences or close friendships
Indifference to praise or criticism from others
Lack of emotional expressivity, appearing cold and aloof
Avoidance of conversational contacts with others

Diagnosis:

Personality Disorder—Trait Specified (DSM-5, p. 770)
Impairment in personality functioning: extreme
Relevant pathological personality traits from Detachment domain: withdrawal, intimacy avoidance, anhedonia, restricted affectivity

Demographics:

Rare Personality Disorder
More common in men than women
Often first apparent in childhood and adolescence with solitariness, poor peer relationships, underachievement in school

Case Study: Mr. Murphy's Story

Background:

50-year-old single man seeking treatment after the death of his dog
Preferred solitude, found talk a waste of time, felt awkward when others initiated relationships
Occasionally spent time in bars but always alone
Employed as security guard, known as a "cold fish" and "loner"
Loved and expressed tenderness towards his dog, considered dogs more sensitive than people
Indifferent to family members, believed he was different from others

Symptoms:

Sadness and tiredness after the dog's death
Trouble sleeping and concentrating
Absence of relationships except with his deceased dog
Intense reaction to the pet's death, longer than normal grieving period

Diagnosis:

Schizoid Personality Disorder (DSM-5, p. 652)
Adjustment Disorder, With Depressed Mood (DSM-5, p. 286) due to the death of his dog.

18.10 Paranoid Personality Disorder

Paranoid Personality Disorder (PPd)

Characteristics:

Pervasive distrust and suspiciousness of others
Interprets motives as malevolent
Questions loyalty or trustworthiness of friends and associates
Unjustified suspicions about spouse's fidelity
Reluctant to confide in others for fear of being used against them
Sensitive to perceived attacks on character and reputation
Quick to react angrily and counterattack when threatened
Extremely litigious
Aloof, hostile or openly angry behavior (DSM-5, p. 649)

Diagnosis:

Personality Disorder—Trait Specified (PPdTS) according to Alternative DSM-5 Model for Personality Disorders
Severe impairment in personality functioning
Relevant descriptive pathological personality traits: suspiciousness and hostility from Negative Affectivity domain (DSM-5, p. 770)

Prevalence:

Common Personality Disorder with a prevalence rate of 2.3% to 4.4% in community populations (DSM-5, p. 649)

Onset:

Often first manifested in childhood or adolescence by solitary behavior, poor peer relationships, social anxiety, school underachievement, and hypersensitivity to teasing.

Case Study: Mr. Grace

85-year-old man caring for bedridden wife
Never treated for mental illness but claims immunity to psychological problems
Career as a lawyer and businessman
Married for 60 years, only trusts his wife
Extremely careful about revealing personal information
Suspects others have underlying motives
Displayed exaggerated suspiciousness throughout life
Involved in "useful work" during waking hours
Spends many hours monitoring stock market investments
Quiet, tense presentation with an inability to relax and restricted affectivity.

Common Features:

Expects exploitation or deception by others
Quick to react angrily and counterattack when threatened
Reluctant to confide in others
Social isolation due to trouble with intimate relationships, bosses, and co-workers.

18.11 Personality Change Due to Another Medical Condition

Personality Change Due to Another Medical Condition

Diagnosis:

Personality disturbance that represents a change from the individual's previous characteristic pattern
Occurs as a result of another (nonmental) medical condition, such as brain tumor or head trauma

Subtypes:

Labile Type: Emotional lability
Disinhibited Type: Poor impulse control
Aggressive Type: Aggressive behavior
Apathetic Type: Marked apathy and indifference
Paranoid Type: Suspiciousness and paranoid ideation
Other Type, Combined Type, or Unspecified Type

Description of Personality Features:

Any of the 25 DSM-5 pathological personality traits can be used to describe the personality features
Level of associated impairment and clinical course depends on the nature and extent of the causative medical disorder

Case Study: Dominick Wozniak

34-year-old white male, former schoolteacher
Unemployed, separated from wife and children for 2 years
Suffered a serious auto accident resulting in coma
Gradual recovery with only supportive medical treatment
No significant neurological signs except minor visual field loss
Verbal IQ and performance IQ around 120

Changes in Personality and Functioning:

Impulsive, argumentative
Frequently misses buses, trains, gets lost
Poor social judgment, financially irresponsible
Disheveled appearance, undercurrent of bitterness and hostility

Neurocognitive Disorder:

Abrupt change in personality and functioning suggests a Neurocognitive Disorder
High IQ inconsistent with generalized loss in intellectual functioning
Prominent features: Impulsivity, argumentativeness, poor judgment, deterioration in self-care

Personality Change Due to Head Trauma:

Changes in personality associated with specific medical factor (history of trauma and CT scan indicating frontal lobe brain damage)
Indicates a Personality Change Due to Head Trauma (DSM 5, p. 682)

18.12 Other Specified Personality Disorder

Personality Disorders: Other Specified

Introduction:

Diagnosis for clinical disturbances not meeting criteria of specific Personality Disorders
Significant distress or impairment in psychosocial functioning
Commonly used diagnosis in previous DSM editions: Personality Disorder Not Otherwise Specified (PDNOS)
New diagnosis in DSM-5: Other Specified Personality Disorder (OSPD)

Background:

Residual category for personality psychopathology not fitting specific types
Alternative Model for Personality Disorders offers flexibility in describing presentations of personality pathology

Case Study: Stubborn Psychiatrist

Dr. Derek Cooper: 34-year-old psychiatrist with long-standing pattern of difficulties with authority and resistance to demands
Childhood history of severe temper tantrums, bossy behavior, sulkiness, insubordination
Brilliant but erratic student, argumentative, self-righteous
Unreliable husband, impaired work performance, marital difficulties
Behavior includes procrastination, stubbornness, forgetfulness (passive resistance)

Characteristics of OSPD:

Resistance to demands for adequate role functioning
Behavior occurs in situations where more assertive behavior is possible
Long-standing pattern

Diagnosis and Discussion:

Diagnosis: Other Specified Personality Disorder (OSPD) with passive-aggressive features
Previous diagnosis: Passive-Aggressive Personality Disorder, no longer included in DSM-5
Behavior patterns do not correspond to one of the 10 specific Personality Disorders.

Goody Two-Shoes

Patient Profile: Maryann West

Background:

Attractive 35-year-old single woman from San Diego
Magazine editor living in Boston neighborhood
Originally referred for psychotherapy by female doctor
Initially resisted therapy, preferring to give help over receiving it
Has a history of problematic relationships with men
Mistrustful of men due to past experiences
No close women friends, except her doctor

Relationship History:

Previously in a "destructive" relationship with an outlaw love who was a heroin addict
Felt responsible for his actions and continued to support him financially
New relationship with another substance abuser
Attracted to unfaithful and abusive men
Avoids nice, monogamous men because they seem "boring"

Personality Traits:

Self-sacrificing and martyrlike behavior
Repeatedly incites angry responses from others, then feels hurt when rejected
Hardworking and good at solving disputes but gets into trouble with her boss
Oldest of four children, often had to care for younger siblings
Rebelled as a teenager after being a "goody two-shoes" in church and school
Engaged in excessive self-sacrifice that is unsolicited by recipients

Psychiatric Diagnosis:

Previously diagnosed with Masochistic Personality Disorder or Self-Defeating Personality Disorder (DSM-III-R)
Controversial diagnosis, as some clinicians argue it perpetuates victim-blaming
Currently classified as Other Specified Personality Disorder in DSM-5 (p. 684)

CHAPTER 19 Paraphilic Disorders

Paraphilic Disorders

Definition: Involves intense sexual arousal to atypical or inappropriate objects, situations, or individuals.

Distinction from Normal Sexual Interest: Difficult to define clear boundary, varies culturally.

Paraphilia vs Paraphilic Disorder:

Paraphilia: Atypical focus of sexual arousal without causing distress or impairment.
Paraphilic Disorder: Paraphilic focus leads to significant negative consequences for the person or others.

Examples of Paraphilic Disorders:

Voyeuristic Disorder: Sexual arousal from observing an unsuspecting naked person.
Exhibitionistic Disorder: Sexual arousal from exposing one's genitals to an unsuspecting person.
Frotteuristic Disorder: Sexual arousal from touching or rubbing against a nonconsenting person.
Sexual Masochism Disorder: Sexual arousal from the act of being humiliated, beaten, bound, or suffering.
Sexual Sadism Disorder: Sexual arousal from inflicting physical or psychological suffering on another person.
Pedophilic Disorder: Sexual arousal from prepubescent children.
Fetishistic Disorder: Sexual arousal from nonliving objects or specific body parts.
Transvestic Disorder: Sexual arousal from cross-dressing.

Characteristics of Paraphilic Disorders:

Fantasies, urges, or behaviors cause distress or impairment.
Mostly diagnosed in men; approximately 1 in 20 cases are women.
Onset before age 13 for most people.

Table 19-1: Characteristic features of specific Paraphilic Disorders.

19.1 Voyeuristic Disorder

Voyeuristic Disorder

Definition:

Sexual arousal from observing an unsuspecting, nonconsenting person who is naked, disrobing, or engaging in sexual activity

Diagnosis:

DSM-5 diagnosis requires:
- Extended period (6 months or more) of recurrent and intense sexual arousal
- Urges have been acted upon with a nonconsenting person
- Or urges and fantasies cause clinically significant distress or impairment in functioning

Exceptions:

Normal during adolescence and puberty
No diagnosis if individual is under 18 years old

Case Study: Mr. Weber

Diagnosed with Voyeuristic Disorder due to:
- Repeated peeping into neighboring apartments using binoculars
- Frequent voyeuristic acts resulting in orgasm or immediate return home
- Continuing appeal despite potential hazardous situations and fear of apprehension
Background:
- Puritanical upbringing with no open displays of erotic behavior
- Watched mother and sisters undress as a child, began peeping at age 10
- First left home to engage in voyeurism at age 17
- Increased activity during major life changes
Psychological Stress:
- Fear of being apprehended is present but not related to anxiety about sexual intercourse.

Additional Information:

Voyeuristic behavior occurs normally during sexual curiosity in adolescence and puberty
Not all individuals with paraphilias can only become aroused during their focus, some may also experience pleasure from normal heterosexual intercourse.

19.2 Exhibitionistic Disorder

Exhibitionistic Disorder

Sexual arousal from exposing genitals to unsuspecting person
Most exhibitionists are men, targets are often women, girls or boys
Majority arrested between late teens and early twenties
One-third of male sexual offenders in US are exhibitionists

Case Study: "Ashamed" Martin Klein

27-year-old engineer with irresistible urges to exhibit to females
Orthodox Jewish background, sex strongly condemned by parents
Father: authoritarian, punitive but relatively uninvolved
Mother: domineering, controlling, intrusive, preoccupied with cleanliness
Found mother's partial nudity sexually arousing as a child
Quiet, withdrawn adolescent, friendly but not intimate with males
Puberty at 13, first ejaculation during sleep
Resisted masturbation due to guilt until age 18
First exhibitionistic behavior occurred before final exams at 18
Exhibited himself to women he didn't know, found their shock and fear stimulating
Felt guilty and ashamed after each incident but couldn't resist urge
Met a woman willing to have intercourse, feared failure and shame
Panic lest he be arrested if he doesn't stop exhibiting behavior.

Diagnosis:

Mr. Klein qualifies for DSM-5 diagnosis of Exhibitionistic Disorder (DSM-5, p. 689)

19.3 Frotteuristic Disorder

Frotteuristic Disorder

Recurrent touching and rubbing against a nonconsenting person for sexual arousal and gratification (frottage)
No reported cases in females
Most common form: genitals rubbed against victim's thighs or buttocks
Alternative: hands rubbed over victim's genitals or breasts
Individuals select crowded places with multiple victims (subway, sports events, elevators, shopping malls)
Victims may not notice initially and do not protest due to lack of certainty
Fantasize exclusive relationship during contact but realize escape is important afterwards

Case Study: Chad Hughes

Referred for psychiatric consultation after second arrest for frotteurism in New York City subway
Engaged in frotteuristic behavior for 10 years, twice a week
Selected women in their 20s and pressed penis against them, fantasizing normal intercourse
Used plastic wrap to avoid staining clothes after ejaculation
Felt guilty but continued the behavior
Expressed extreme guilt during interview, cried about fear of exposure
No obvious mental problems other than being socially inept and unassertive with women.

Discussion: "Underground Sex"

Hughes engaged in frotteuristic behavior towards unsuspecting victims
Markedly distressed by his actions, qualifying for Frotteuristic Disorder diagnosis (DSM-5)
Typical characteristics include choosing crowded places with multiple potential victims.

19.4 Sexual Masochism Disorder

Sexual Masochism Disorder

Characteristics:

Sexually arousing fantasies of being humiliated, beaten, bound, or otherwise made to suffer
Markedly distressing or impairing to the individual's social and occupational functioning
Behaviors can be self-inflicted or with a consenting partner
Well-planned dominant-submissive relationships

Prevalence:

More people consider themselves masochistic than sadistic
Onset typically occurs during early adulthood
Slightly more prevalent in males than females

Specific Cases:

Ms. Romano's Case:
- 25-year-old female graduate student
- Marital discord and depression
- Experienced sexual excitement from being beaten or punished, especially by strangers
- Engaged in masochistic extramarital activities
- Distressed about potential negative impact on marriage
- Diagnosis: Sexual Masochism Disorder (DSM-5)

Additional Information:

Autoerotic partial asphyxiation: Dangerous, sometimes fatal masochistic activity involving induced state of asphxia at orgasm to enhance pleasure.
Masochistic sexual fantasies often begin in childhood.

19.5 Sexual Sadism Disorder

Sexual Sadism Disorder

Definition: Arousal from the physical or psychological suffering of another person. Derived from Marquis de Sade's novels on inflicting pain as a source of sexual pleasure.

Diagnosis:

DSM-5 diagnosis for acting upon sadistic urges with an unwilling person
Markedly distressing fantasies or behaviors negatively impacting relationships

Characteristics:

Desire for sexual/psychological domination
Range from non-physically harmful acts to criminal behavior
Domination through restraint, imprisonment, whipping, burning, biting, cutting, rape, murder, mutilation

Case Study: "Leather Jason"

35-year-old married writer, Mr. Stavros
Homosexual fantasies since childhood
Aroused by homoerotic sadistic pornography
Married for social propriety and to diminish sadistic impulses
Typical masturbation fantasies: man bound, tortured, killed
Intense arousal from criminal activities described in magazines
Engaged in sadistic sexual activities with consenting partners at homosexual S&M bars
- Whipping, threatening to burn, forcing oral sex
Wife dissatisfied with marriage, became more hostile and demanding
Increasing work pressures and sadistic impulses led to bounding a partner and cutting his arm
Fear of losing control and killing a sexual partner

Conclusion:

Mr. Stavros' long history of recurrent sadistic fantasies and acting on them qualifies for the DSM-5 diagnosis of Sexual Sadism Disorder.

19.6 Pedophilic Disorder

Pedophilic Disorder

Definition: Recurrent and intense sexually arousing fantasies, urges, or behaviors involving sexual activity with prepubescent children.

Diagnosis: DSM-5 diagnosis for individuals experiencing such attractions causing distress or interpersonal difficulty.

Characteristics:

Strong sexual interest in children around puberty
No cure developed but therapies can reduce incidence of child sexual abuse

Case Study: Dr. Conrad

36-year-old child psychiatrist arrested and convicted for fondling neighborhood boys
Considered caring and supportive of children, had been Cub Scout leader and Big Brothers member

Background:

Father was a workaholic physician spending little time with family
No marriage or sexual attraction toward females or adults
Childhood experiences: dismayed by male friends' attraction to girls, "Doctor" games with other boys leading to mutual masturbation, first sexual experience at age 6 by a 15-year-old male counselor

Psycho-sexual Development: Suspected he was homosexual, continued erotic urges and fantasies about boys between ages 6 and 12.

Actions and Concerns: Fondled young boys, believed they were sharing pleasurable feelings together, feared destroying reputation, friendships, and career.

Diagnosis for Dr. Conrad: Pedophilic Disorder (DSM-5) with Exclusive Type subtype and Sexually Attracted to Males specifier.

19.7 Fetishistic Disorder

Fetishistic Disorder

Characteristics:

Atypical sexual focus on nonliving objects (fetishes)
Articles of clothing or footwear, rubber and rubber items, leather, soft materials or fabrics, or nongenital body parts
Sexual urges, fantasies, or behaviors causing significant psychosocial distress
Detrimental effects on important areas of the individual's life

Case Study: Kurt O’Brien

32-year-old single, successful freelance photographer
Chief complaint: "abnormal sex drive"
Sexual arousal began at age 7 with discovery of pornographic magazine
Preferred sexual activity involves women's panties
Stolen panties from his older sister and other women
Masturbated into stolen panties, saved in private cache
Preferred partners were prostitutes wearing panties
Avoided socializing with "nice women" due to fear of rejection
Feels uncomfortable with intimate romantic relationships
Sought consultation after mother's death, unsure about giving up fetishistic activities

Diagnosis:

Fetishistic Disorder (DSM-5) if the fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Not a disorder if the fetishistic urge is accepted and incorporated into sexual activities with a willing partner.

Implications:

Fetishistic Disorder is not based on the intensity of sex drive but rather the atypical focus of sexual arousal.
Treatment may involve finding an accepting partner who is willing to incorporate the fetishistic desire into their sexual activities, eliminating the disorder diagnosis.

19.8 Transvestic Disorder

Transvestic Disorder (TD)

Sexual arousal from dressing as opposite sex
Diagnosis requires distress or impairment
No diagnosis for habitual cross-dressing without sexual excitement
DSM-5 definition: "clinically significant distress or impairment in social, occupational, or other important areas of functioning" (p. 702)
Can include purging and acquisition behavior
Not applicable to individuals with Gender Dysphoria (Section 14.2)
Individuals may progress from search for sexual excitement to simple relief from stress
Diagnosis does not guarantee development of gender dysphoria or need for hormonal/surgical procedures
Rare in females, but some reported cases exist
X-Dressing: a form of Transvestic Disorder
- Individual is distressed by cross-dressing behavior and its impact on functioning
- Characteristics: heterosexual, masculine demeanor, occasional use of female clothing
  - Inconspicuous items (underwear, pink ring)
  - Progression from occasional to regular dressing as a woman
  - Increased intensity with age and exposure to related materials
  - Tranquilizing effect during stressful times
- Onset in childhood or adolescence
- History of family conflict and disruptions
- Intensity varies based on circumstances
- Cross-dressing may be a source of sexual excitement but not always necessary for it.

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LEARNING DSM-5 BY CASE EXAMPLE by Michael B. First, Andrew E. Skodol

Contents

Introduction

Chapter 1. Neurodevelopmental Disorders.

INTELLECTUAL DISABILITIES.

1.1 Intellectual Disability (Intellectual Developmental Disorder)

Down Syndrome

The Enigma

COMMUNICATION DISORDERS

1.2 Language Disorder

1.3 Speech Sound Disorder

1.4 Childhood-Onset Fluency Disorder (Stuttering)

1.5 Social (Pragmatic) Communication Disorder

AUTISM SPECTRUM DISORDER

1.6 Autism Spectrum Disorder

Echo

The Roman

Rocking and Reading

Reggie’s Regression

ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER

1.7 Attention-Deficit/Hyperactivity Disorder

Daydreamer

Into Everything

A Wandering Mind

SPECIFIC LEARNING DISORDER

1.8 Specific Learning Disorder

MOTOR DISORDERS.

1.9 Developmental Coordination Disorder

1.10 Stereotypic Movement Disorder

TIC DISORDERS

1.11 Tic Disorders

CHAPTER 2 Schizophrenia Spectrum and Other Psychotic Disorders

2.1 Schizophrenia

Under Surveillance

Eating Wires

Low Life Level

The Witch

Star Wars

2.2 Schizophreniform Disorder

Postpartum Piety

2.3 Schizoaffective Disorder

2.4 Delusional Disorder

Contract on My Life

Dear Doctor

Unfaithful Wife

Fleas

2.5 Brief Psychotic Disorder

2.6 Catatonia Associated With Another Mental Disorder/Catatonic Disorder Due to Another Medical Condition

2.7 Substancel/Medication-Induced Psychotic Disorder

2.8 Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

Sex Problem

CHAPTER 3 Bipolar and Related Disorders

3.1 Bipolar 1 Disorder

Radar Messages

Triple Divorcée

Roller Coaster

Wealthy Widow

Praying Athlete

You May Keep the Yacht

3.2 Bipolar II Disorder

3.3 Cyclothymic Disorder

3.4 Substance/Medication-Induced Bipolar and Related Disorder

CHAPTER 4 Depressive Disorders

4.1 Disruptive Mood Dysregulation Disorder

Titanic Tantrums

4.2 Major Depressive Disorder

Worthless Wife

Stonemason

Three Voices

It’s Typical?

New Mom

A Child Is Crying

A Perfect Checklist

The Mixed-Up Waiter