DSM 

* History

* Purpose

* % with MI

1950’s

·      DSM V – May 2013

·      Used to meet accountability and financial standards

·      Mental Illness:  26% of Americans have some type of psychiatric problem

 Assessment & Treatment of people with mental illness is ongoing

 Outside interest

Diagnosis is based on person who is making the diagnosis

Diagnosis is based on perception of person making the diagnosis

Ongoing consultation and supervision is important

o   With DSM-IV-TR - - look at different individuals involved in the development of the manual

§  56% had a direct connection with pharmaceutical companies

How do we determine what is psychopathological today?

* DSM – Biological, Psychological, and Social aspects

Biological Aspects in psychopathology / DSM

Medical Problems

Identify the medical problems, Review for side effects as a result of substance use/abuse or medications,  Monitor medications – proper administration, combinations, side effects, impact of not taking, reasons for not taking, are there cultural considerations.  KNOW side effects.

Historical Background of the DSM

Diagnostic and Statistical Manual of Mental Disorders

Mental Disorders 

ICD:  International Classification of Diseases

A classification system for mental disorders

Used to collect statistical information.

Sourcebook

Intended to provide a comprehensive and convenient reference record of the clinical and research support 

Versions I, II & III:  versions of the 150DSM IV lit reviews.

Version IV:  Reports of data reanalysis, field trials & final executive summary of rational for decisions

For use in clinical, educational and research settings.  

To be used by individuals with appropriate clinical training & experience in diagnosis.

Guidelines

1st step in a comprehensive evaluation to formulate adequate treatment planning

History of Mental Illness

                  Greek and Roman Times

o   Relaxation:  cruises, spa’s

o   Rituals & Prayers:  organize thinking patterns & ways of life

o   Religion:  belief in MI being the work of the devil – being possessed, satanic beliefs 

History of Treatment for Mental Illness

·      Identified many psychiatric diagnoses in the DSM

o   Mind & body are connected

o   Beliefs can cause physical illnesses – can impact psychological functioning of the individual

o   Primary Passions

§  Labido Functions:  fear, joy, & intense desire

§  Hallucinations, discomfort

·      Carefully recorded systemic observations – documentation

Leonardo DaVinci, painter & scientist: 

·      Invented the Rorschach test - used in diagnosis

·      Paid attention to responses to cloud shapes

Historic Contributions

Dichotomy - mild mental illness vs. serious mental illness

o   Neurosis, problems in living

o   Treatment options – interventions based on particular diagnosis

o   Origin of problem – organic or psychological?

·      DaVinci’s theory turned thought processes

o   Human suffering was truly human – not Satanic

·      QUOTE:  “The fault, dear Brutus, lies not in our stars, but in ourselves…”

History of Social Work within Mental Health / Psychopathology

·      1906 = 1^st SW’ers in mental health worked at Manhattan State Hospital in NY, Admissions, took social histories

·      Dorothea Dix – 1 of the 1^st to work with individuals = called it “Social Case Work”:  Method of intervention:  Home Visits – looked at problems & reasons for readmissions;    She didn’t like hospital conditions and/or treatments in hospitals – began writing, publishing & advocating for changes – made a big difference in MH services

Current Trends in MH

·      3 major developments in the past 60 years:

o   Discovery & increasing use of psychotropic meds

§  Some initially marked in 1950’s:  Haldol (1958), antidepressants, lithium (1969)

o   Deinstitutionalization began in 1963

o   Managed MH care has changed who, how, when, where, and what MH issues receive treatment

Two Major Models of Mental Illness

Interactional Model (1950’s)

Medical

o   Compared to physical illness

o   Internal condition has caused a disturbance in the patient

o   DSM Diagnosis = labeling the person and the conditions.  Labels can follow person throughout their life.  Label can become self-fulfilling – people can act upon the diagnosis later in life.  Pre-existing conditions can be problematic for healthcare.

o   Examples:  Schizophrenia – group of disorders / Bipolar Disorder (previously Manic Depressive)

o   Interaction of Person and Environment  o   Psychoanalytical Model

o   Multidimensional dynamics in a family – person is seen in relation to the interaction with others:  §  Personal Disabilities, §  Antisocial Acts – such as criminal activities or other deviations, §  Deterioration of the Brain – can lead to personality changes, dementia, alcohol deterioration, …

o   Looks at labels as a possible cause for mental illness, such as diagnosis for depression – feeding off the diagnosis and exhibiting with increased symptomology.

Social Structures associated with mental illness

·      Poor,  Living area,  Age, 

·      Marital Status - Single, divorced &/or widowed have the highest amount of mental health problems

·      Race – historically, more African Americans have been diagnosed.  Currently, Females, age 50+, are more likely to be receiving and hospitalized for mental health issues.  

·      After deinstitutionalization

·      Covered under the Community Mental Health Centers Act of 1963

Emphasis of Community Mental Health

·      Early Diagnosis:  important – for treatment

·      Accessible centers that are community based

·      Comprehensive services which include:

o   Inpatient Care: if condition cannot be managed on an outpatient basis

o   Hospitalization:  danger to self, danger to others, functional interference – cannot handle ADLs and acting / exhibiting behaviors outside of the norm

o   Partial Hospitalization

o   Emergency Care

* Education regarding problem / label is very important

Understanding the DSM-IV-TR Axis

Competency Based Practice

·      Examine and Document:  read referral, pay attention to information provided versus information missing.  Is there anything that needs further exploration and/or clarification? 

·      Reason for Referral:  What events led to this referral? Who made the referral and why?

·      Preceding Events:  Are there contributing conditions? 

·      Contributing Conditions:  What is different now than in the past?

·      Client Competencies:  Can the client provide accurate information?

·      Intrapersonal Issues:

·      Patterns of interpersonal relationships:  do they get along with others?

·      Social Context:  Is the problem happening at a specific time?  Is it worse at different times, patterns?

·      Support Networks:  Who is involved?  Positive or negative supports?  

 Axis I      Clinical Disorders / Other conditions that may be a focus of clinical attention 

    Axis II     Personality Disorders / Mental Retardation        

    Axis III    General Medical Conditions

    Axis IV    Psychosocial and Environmental Problems

    Axis V     GAF - Global Assessment of Functioning

Clinical Disorders

All clinical syndromes listed except personality disorders & MR

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Personality Disorder NOS

Medical conditions that may influence or worsen Axis I and Axis II disorders

All general medical conditions

ICD codes can be used

None (no medical condition)

·      If the medical condition has caused the disorder, it is recorded on Axis I with the phrase, “due to”

§  Example:  “Mood Disorder, due to Hypothyroidism, with Depressive Features”  293.83

Problems with primary support group

*Childhood V61.9

*Adult V61.9

*Parent-Child V61.20

Problems related to the social environment V62.4

Educational Problems V62.3

Occupational Problems V62.2

Housing Problems

Economic Problems

Problems with access to health care services

Problems related to interaction with the legal system/crime

Other psychosocial and environmental problems

Global Assessment Functioning (GAF) Scale (pages 22-23)

·      Indication of clients overall level of functioning:  Using a number between 1 (indicating persistent danger of hurting self or others) to 100 (indicating superior functioning that shows the person’s current level of functioning)

·      Assess psychological, occupational, and social functioning

·      Score = 0   Inadequate information or time to assess person’s functioning. 

·      Score = 91-100      Superior functioning in wide range of activities, positive qualities

·      Score = 90             Absent or minimal symptoms

·      Score = 80             Transient symptoms seen as expectable reactions to psychosocial stressors

·      Score = 70             Mild symptoms

·      Score = 60             Moderate symptoms

·      Score = 50             Serious symptoms

·      Score = 40             Some impairment in reality testing or communication

·      Score = 30             Behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment

·      Score = 20             Some danger of hurting self or others or occasionally fails to maintain minimal hygiene

·      Score = 1-10          Person poses a persistent danger of severely hurting him or herself or others or they have a persistent inability to maintain minimal personal hygiene or show serious suicidal acts with clear expectation of death as the outcome

What are the ID Levels for Mental Retardation
Mild

Moderate

Severe

Profound 

Mild:  50/55-70

Moderate:  35-50/55

Severe:  20/25-35/40

Profound:  Less than 20/25

How are Learning Disorders Determined?

Reading Disorder

Mathematics Disorder

Disorder of Written Expression

Learning Disorder, NOS

·      Major difficulties in social interaction & unusual patterns of interest & behavior while cognitive & communication skills remain in tact

·      Eccentric – socially inept, egocentric, & preoccupied w/abstract, narrow interests

·      Part of autism spectrum – with difficulties with social interaction w/restricted & repetitive patterns of behavior & interest

·      Key diagnostic distinction:  relative preservation of linguistic & cognitive development

Severe disorder with onset before age 3 with abnormalities in social functioning, language, and communication, and by unusual interests & behaviors.  Spectrum Disorder.  Characteristics in different combinations & degrees of severity

Severe neurological developmental disorder,  girls

o   Deceleration of head growth b/t ages 5 years & 48 months

o   Loss of previously acquired purposeful hand skills w/subsequent development of stereotyped hand movements

o   Loss of social engagement early on though social interaction often develops later

o   Appearance of poorly coordinated gait or trunk movements

o   Severely impaired expressive & receptive language development w/severe psychomotor retardation

o   Child is apparently moving through normal development & shows a significant loss of previously acquired language, social, and adaptive behavior occurring before age 10

o   Significant loss of previously acquired skills before age 10

o   Loss in 2 or more of the following areas:  expressive or receptive language, social skills or adaptive behavior, bowel/bladder control, play, motor skills

o   Abnormalities in 2 or more areas of functioning: 

§  Qualitative impairment in social interaction

§  Quantitative impairment in communication

§  Restricted, repetitive, & stereotyped patterns of behavior, interests, & activities

·      2 lists of symptoms – 1^st:  inattention, poor concentration, & disorganization.  2^nd – hyperactivity & behavioral impulsivity

·      Controversial disorder due to how diagnosed & treated

·      Related:  environmental toxins, drug exposure in utero, & h/o child abuse & multiple foster care placements

·      Poor concentration & disorganized “motormouth” – talks endlessly about everything & anything to anyone who will listen.  Constant motion.  Fails to complete assignments in school.  Forgets chores. 

·      Key behaviors in inattention & hyperactivity impulsivity.

·      Diagnosis:  key symptoms must occur for 6+ months with significant impairment in at least 2 situations of a child’s life.  Some symptoms begin before age 7.

·      Symptoms do not occur during a Pervasive Developmental Disorder, Psychotic Disorder, or Schizophrenia.  Symptoms are not better explained by a mood, anxiety, dissociative or personality disorder.

o   Predominantly Inattentive Type (ADHD-PI): 

§  Problems mainly with symptoms of inattention

§  Less likely to act out of have difficulty getting along with others

§  Overlooked due to being quiet,…not paying attention to what they are doing

o   Predominantly Hyperactive-Impulsive Type (ADHD-HI):

§  Problems with symptoms of hyperactivity-impulsivity

§  All over the place and rarely sits still

§  May be aggressive, defiant, oppositional, and rejected by peers

§  Placement in special ed or suspension is common

o   Combined Type (ADHD-C):

§  Problems with both symptoms of inattention and hyperactivity-impulsivity

Conduct Disorder:  

·      Pattern of repetitive behavior where the rights of

others or social norms are violated

·      Children who violate societal rules &

risk serious trouble. 

·      Explore has child violated rules, age-appropriate

social norms, or the rights of others for 12+ months

·      3 or more symptoms in prior 6 months:

o   Aggression against people or animals

o   Property destruction

o   Lying or theft

o   Serious rule violation

·      Specifiers:  Mild, Moderate, or Severe

·      Subtypes indicate onset:  childhood, adolescent, unspecified

Oppositional Defiant Disorder:

 Children/adolescents usually show a pattern of defiant & disobedient behavior including resistance to authority figures.  Not as severe as Conduct disorder.

·      Ongoing pattern of disobedient, hostile, and defiant

behavior toward authority figures,

beyond normal behaviors, appears to be stubborn

·      Diagnosis:

o   Defiance must interfere with ability to function

o   Defiance cannot be result of another disorder

o   Problem for 6+ months

o   Behaviors:  loosing temper, argumentative, defiance towards rules/requests, annoying to others, blame others, angry, resentful, spiteful/vindictive

Disruptive Behavior Disorder, NOS:

 Disruptive behavior where problems are occurring but not enough symptoms to consider a conduct or ODD or not enough info

·      Catchall diagnosis - used when insufficient info for ADHD diagnosis. 

·      Significantly impaired interpersonal or family relationships and/or disturbed school functioning

Separation Anxiety Disorder (81)

·      

Excessive worries that are overwhelming,

develops between 8-10 years old

·      Evident when leaving or thought of leaving significant person(s)

·      Fear(s) may appear irrational with extremes to avoid separation, may exhibit with physical complaints

·      Diagnosis:  age-inappropriate, excessive, &

disabling anxiety @ being apart from parents or home.  

SAD usually identified after a major stressful event

A.  Markedly disturbed & developmentally inappropriate social relatedness in most contexts, prior to 5yo

Either:  Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions OR Diffuse attachments as manifest by indiscriminate sociability with marked ability to exhibit appropriate selective attachments

B.  Not accounted for by dev delay or PDD

C.  Pathogenic care aeb 1 of 3:  persistent disregard of basic emotional needs for comfort, stimulation, and affection; persistent disregard of basic physical needs; or repeated changes in caregiver that prevent attachments

D.  Presumption that care in C is responsible for disturbed behavior in A

Mental Retardation is present in diagnoses?

ADHD

RAD

ODD

Separation Anxiety Disorder

Asperger's

Children diagnosed with MR - should ONLY be diagnosed with ADHD IF inattention or hyperactivity is excessive for the child's mental age.  

Children diagnosed with MR - RAD - ONLY if clear that characteristic problems in formation of selective attachments are not a function of the MR.

Children diagnosed with MR - ODD - ONLY if oppositional behavior is markedly greater than is commonly observed among individuals of comparable age, gender & severity of MR

Asperger's:  MR can be present in severe cases.

SepAnxietyDisorder:  No MR as part of the SAD diagnosis

·      Deterioration of memory – recent

·      Does not feel like doing anything

·      Mood or personality changes

·      Confusion

·      Takes longer than usual to perform chores

·      Recognition problems increase

·      Escalating memory loss and confusion

·      Repetitive statements

·      Occasional muscle jerking or twitching

·      Difficulty reading, writing, or understanding numbers

·      Problems thinking logically

·      Struggles to find “the right words”

·      Needs close supervision

·      May exhibit suspiciousness, irritability, or restlessness

·      May have trouble bathing or with self-care

Late·      Recognition problems increase

·      Escalating memory loss and confusion

·      Repetitive statements

·      Occasional muscle jerking or twitching

·      Difficulty reading, writing, or understanding numbers

·      Problems thinking logically

·      Struggles to find “the right words”

·      Needs close supervision

·      May exhibit suspiciousness, irritability, or restlessness

·      May have trouble bathing or with self-care

·      Nutrition problem

·      Recognition problems

·      Does not distinguish familiar everyday objects

·      Becomes incontinent

·      Unable to care for self

·      Unable to communicate with others

Pervasive Developmental Disorder

PDD (63)

 shows social, communication, & behavioral 

·      Constellation of symptoms characterized by a triad of atypical communication, social impairments, including atypical social interactions, & atypical responses to social & perceptual stimuli in the environment

·      Symptoms to watch for – failure in development of paralinguistic signaling system characterized by poor eye contact, failure to develop a protodeclarative point, & lack of facial affect that demonstrates reciprocal engagement or shared attention

·      Communication:  most pervasive is a failure to make compensatory use of gestural communication in the absence of spoken capacity

·      Social Interactions:  unable to develop the types of social relationships expected for the child’s age

·      Restricted Behaviors, Interests, and Activities:  Preoccupation with restricted & narrow interests as well as preoccupation with parts of objects

Autistic Disorder (67)

The Clinical Picture 

o   Serious abnormalities in communication & language, social impairments, & restrictive & repetitive behaviors & interest beginning before the child is age 3

o   Onset is gradual

o   Spectrum disorder – characteristics are expressed in many different combo’s with varying degrees of severity

 Characterized by the child’s social deficits.

·      Other Co-Occurring Symptoms         

Sensory Abnormalities

·      Differential Assessment:  MR, Epilepsy, hyperactivity, anxiety/fear, mood problems & selected mutism

6 or more of the following 3 items with at least 2 from (1), and 1 form (2) and (3).

1. Impairment in social interaction (2:4 - nonverbal behaviors; lack of peer relationships; lack of ability to seek/share enjoyment; interests, acheivement; lack or social/emotional reciprocity)
2. .  Impairments in communication (1:4 - delay in or lack of spoken language; marked impairment in ability to initiate/sustain conversation; stereotyped & repetitive use of language or idiosyncratic language; or lack of varied, spontaneous make-believe play or social imitative play appropriate to dev. level)
3.   Restricted repetitive & stereotyped patterns of behavior, interests, & activites (1:4 - encompassing preoccupation w/1 or more sterotyped & restricted patterns of interest that is abnormal in intensity or focus; inflexible adherence to specific, nonfunctional routines or rituals; stereotyped & repetitive motor mannerisms; persistent preoccupation with parts of objects

B.  Delays or abnormal functioning in at least 1 of the following areas, w/onset prior to age 3:  social interaction, language used in social communication, symbolic or imaginative play

C.  Disturbance is not better accounted for by Rett's Disorder or Childhood Disintegrative Disorder

Tourette's Disorder

Chronic Motor or Vocal Tic Disorder

Transietn Tic Disorder

Tic Disorder NOS

1. Mutliple motor tics & 1 or more vocal tics present 
2. Occur many times daily - nearly every day or intermittently throughout a period of more than 1 year & during this period never a tic-free period of more than 3 consecutive months
3. Onset prior to age 18
4. Disturbance not due to direct physiological effects of a substance or general medical condition

TIC:  sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization

1. Single or multiple motor or vocal tics present at some time during illness
2. Tics occur many times daily nearly every day or intermittently through period of more than 1 year & during period never tic-free more than 3 consec months
3. Onset prior to age 18
4. Disturbance not due ot physicological efects of substance or general medical condition

1. Single/multiple motor and/or vocal tics
2. Occur many times a day, nearly every day for at least 4 weeks, no longer than 12 consecutive months
3. Onset prior to age 18
4. Disturbance not due to physiological effects of substance or general medical condition
5. Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder

Specify:  Single or Recurrent

·      Worry excessively about almost everything for at least 6 months

·      Pervasive and uncontrollable quality of worry leads to chronic feelings of anxiety

·      In severe form, the person’s entire life is saturated with anxiety and severely affects persons level of functioning

·      People usually realize that their anxiety is more intense than the situation warrants, but they cannot reduce the anxiety

·      These are people who have problems going to sleep or staying asleep, have fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, frequently going to the bathroom, feeling out of breath, and having hot flashes

·      Other disorders that commonly co-occur are : major depression, substance abuse disorders, and other anxiety disorders

Childhood Communication Disorders

(5 - CEMPS)

Communication Disorder, NOS (C)

Expressive Language Disorder (E)

Mixed Receptive-Expressive Language Disorder (M)

Phonological Disorder (P)

Stuttering (S)

Expressive Language Disorder

(TIP-D)

1. Standardized measures indicate expressive language development deficits
2. Deficits interfere with academic or occupational acheivement or with social communication
3. Does not meet criteria for Mixed Receptive-Expressive Language Disorder or PDD
4. If MR, speech-motor or sensory deficit, or environmental deprivation is present, language difficulties are in excess of those usually associated with these problems

Phonological Disorder

(Previously Articulation Disorder)

(SOAD)

1. Failure to use expected speech sounds that are appropriate for age and dialect
2. Difficulties in speech sound production interfere with academic or occupational acheivement or with social communication
3. If MR, speech-motor or sensory deficit, or environmental deprevation is present, speech difficulties are in excess of those usually associated w/these problems

Stuttering

(FOAD)

1. Disturbance in normal fluency & time patterns of speech (sound, syllable repetitions, sound prolongations, interjections, broken words, audible or silent blocking, circumlocutions, word produced w/excess of physical tension, monosyllabic whole-word repetitions
2. Disturbance in fluency interferes w/academic/occupational achievement or social communication
3. If speech-motor or sensory deficit is present, speech difficulties in excess of those associated with these problems

1. Standardized measures indicate receptive & expressive language development deficits
2. Deficits interfere with academic or occupational acheivement or with social communication
3. Does not meet criteria for PDD
4. If MR, speech-motor or sensory deficit, or environmental deprivation is present, language difficulties are in excess of those usually associated with these problems

Progressive deterioration of brain functions that is marked by impairment of memory, confusion, and an inability to concentrate.

·      Disturbed consciousness & cognition or perception that develops acutely, fluctuates, & is attributable to a physical disorder

·      Impaired ability to attend to environment

·      Underlying medical condition or drug intoxication/withdrawal

·      Acute change or fluctuation in mental status plus inattention

·      Disorganized thinking or altered level of consciousness

·      Sudden deterioration in cognitive functions

·      Prodromal phase – malaise, restlessness, poor concentration, anxiety, irritability, sleep-disturbance, nightmares

·      Progressive memory impairment in presence of other cognitive deficits & describes and acquired, persistent, global impairment of cognitive/intellectual processes severe enough to interfere with social or occupational functioning.

·      Etiology:  brain neuronal loss that may be due to neuronal degeneration or to cell death secondary to trauma, infarction, hypoxia, infection, or hydrocephalus.

·      Gradual or acute onset & shows a progressive course

o   Alzheimer’s

o   Vascular

o   HIV

o   Head Trauma

o   Parkinson’s

o   Huntington’s

o   Pick’s

o   Creutzfeldt-Jakob

Erosion of recent and remote memory

Impairment in 1 or more of the following areas:

o   Aphasia:  Misuse of words or inability to use words correctly

o   Apraxia:  Unable to perform motor activities even though physical ability remains intact

o   Agnosia:  unable to recognize objects even though sensory abilities remain intact

o   Loss of executive functioning - unable to plan, organize, think abstractly

Amnestic Disorder diagnostic criteria

Memory impairment is apparent by the person's inability to learn new information or to recall previously learned info

Does not occur during the course of delirium or dementia

Can last for at least a month or longer

• ·      For those d/o’s related to the use of a substance, 2 descriptive categories to choose from when making the diagnosis – dependence or abuse
• The DSM for dependence or abuse do not address the subjective reasons of why users prefer a particular substance.  Terms – Denial and Cravings – are no part of the DSM diagnostic criteria because these conditions are difficult to evaluate.

·      Those d/o’s induced by the use of the substance, the 2 categories used to describe the effects – intoxication or withdrawal

The pattern of substance use leads to significant distress or impairment in a single 12-month period by three or more of:

·      Tolerance – increased in use needed to achieve the same effect or with continued use, the same amount of the substance has less of an effect

·      Withdrawal – demonstrated by the substance’s characteristic withdrawal syndrome is experienced or the substance (or one closely related) is used to avoid or relieve withdrawal symptoms

·      The amount or duration of use is often greater than intended

·      Unsuccessful efforts to control or reduce use

·      Spends a lot of time using the substance and recovering from its effects or to obtain the substance

·      Important social, work or recreational activities are given up or reduced because of use

·      Continued use despite negative consequences

The pattern of substance use causes significant distress or impairment in a single 12-month period or by one or more of:

·      Because of repeated use, the person fails to carry out major work, home or school obligations

·      Continued use of the substance even when it is physically dangerous to do so

·      Repeatedly has legal problems resulting from substance use

·      Despite knowing the use has caused (or worsened) social or interpersonal problems, the person continues to use the substance

·      Keep in mind the person has never met criteria for substance dependence

Diagnostic Criteria for Substance Intoxication

·      The person develops a reversible syndrome due to recent use of (or exposure to ) a substance that affects the central nervous system

·      During or shortly after using the substance, the person develops clinically important behavioral or psychological changes that are maladaptive

·      This condition is not the result of a general medical condition nor better explained by another mental disorder

Diagnostic Criteria for Substance Withdrawal

·      A syndrome specific to a substance develops when the person who has used it frequently and for a long time suddenly stops or markedly reduces its intake

·      Causes clinically important distress or impairs work, social or other functioning

·      This syndrome is not the result of a general medical condition nor better explained by another mental disorder

·      Paranoid type – preoccupation w/delusions or auditory hallucinations

·      Disorganized type – disorganized speech and behavior and flat or inappropriate affect are prominent

·      Catatonic type – characteristic motor symptoms are foremost

·      Undifferentiated type – considered a nonspecific category and used when none of the other subtype features are prominent

·      Residual type – absence of prominent positive symptoms but a continuing evidence of the disturbance is shown

Paranoid-type Schizophrenia (185)

·

      Central Characteristics:  Delusions and hallucinations that wax & wane across recurrent psychotic episodes

·      Behaviors & physical appearance = relatively unaffected

·      Level of social functioning sets them apart.

·      Symptoms start later in life, average age around 35

·      Key Feature:  Combination of false beliefs and auditory hallucinations, more “normal” emotions & cognitive functioning.

·      Delusions – persecution or being harmed by others

·      Conceptual Map for Paranoid-Type Schizophrenia – page 186

·      May be at higher risk for suicidal or violent behavior toward self or others when under delusional influence

·      “It is usually the hallucinations that “command” the person to complete these behaviors”

Disorganized-Type Schizophrenia (187)

·      

“Hebephrenic”

·      Disorganized speech, behavior, and flat affect coupled with inappropriate emotional responses to situations

·      Talks gibberish, neglects hygiene and appearance

·      Chronic problems

Catatonic-Type Schizophrenia (188)

·   

  Negativism:     demonstrated when the person refuses to follow instructions without an apparent motive or maintains a rigid posture despite attempts to move them

·      Mutism:          refusal to talk

·      Mannerisms:   unnecessary movements that are part of goal-directed behavior such as the grand gesture of the pen when signing one’s name

·      Stereotypy:     behaviors that are not goal-directed, such as folding a crease in a piece of paper over and over until it eventually shreds

·      Posturing:        person spontaneously poses or assumes a position that is bizarre or inappropriate

·      Catalepsy:       person poses or assumes a position that is bizarre or inappropriate and holds it for hours

·      Waxy flexibility:         person resists any attempts to change his/her position

·      Hyperactivity:            behavior that has no apparent purpose and is not influenced by external stimuli

·      Echolalia:         Involuntary and meaningless repetitions of another’s words

·      Echopraxia:     Mimicking the physical actions and movements of others

Undifferentiated-Type Schizophrenia (191)

·      Subtype characterized by psychotic symptoms (delusions, disorganized behavior/speech, flat affect, hallucinations) BUT does not meet diagnostic criteria for other types.

·      Characteristics present but not enough to determine a definitive diagnosis

·      Positive and negative symptoms with no 1 dominant symptom

Residual-Type Schizophrenia (192)

·      Characterized by past history showing at least 1 episode of schizo but currently no + symptoms present

·      May represent a transition b/t a full-blown episode & complete remission OR may continue for years w/out further psychotic episodes

·      Prior psychotic episodes (at least 1 or more)

·      “Leftovers” or remnants of symptoms may be found to indicate disorder has not completely resolved.

·      Diagnosis is a “filler” – person may have either been treated or spontaneously improved with no symptoms for assessment of active disorder

·      Schizophreniform disorder

   Characterized by experiences of schizophrenic symptoms for more than 1 month but less than 6 months

o   May recover completely with no residual effects

o   May be able to function in both social and occupational functioning

·      Schizoaffective disorder

o   Person shows symptoms of schizophrenia that are combined with either mania or severe depression

o   Presence of both psychotic and mood disturbances for uninterrupted period of time

Minimum of 2 weeks of delusions or hallucinations in the absence of a mood episode

·      Delusional disorder

o   Delusions that persist for at least 1 month

o   Often involves prominent psychotic themes – persistent belief

o   Brief Reactive Psychosis

o   Experiences of delusions, hallucinations, and/or disorganized speech and behavior lasting for at least 1 day – can last up to 30 days

o   Typically identified in person who has experienced some overwhelming and stressful situation, birth, death, life-threatening accident – major event

o   Returns to normal

·      Shared psychotic disorder

o   

Formerly known as Folie a Deux (double insanity)

o   Person develops delusions after associating with 1 or more independently psychotic delusional people

a.     Before a relapse, person usually goes through the prodromal period – emotional disturbance then full blown psychotic symptoms – up to 4 weeks

·      Delusions of Persecution – person’s beliefs that they are being stalked, tricked, framed or hunted, paranoia, talks of international spy rings being after them

·      Delusions of Reference – attaches meaning to the actions of others or to various objects even when there is no information to confirm experience

·      Delusions of Grandeur – belief that they are a significant figure, like a movie star

·      Somatic Delusions – revolve around person believing he/she has a terrible illness

·      Religious Delusions – belief that person has a special relationship with God, claims God is speaking directly to them or that they are God

·      Erotomania Delusions – false ideas and feelings about relationships that do not exist

·      Delusions of control – belief that another person, group, or external force controls their thoughts, feelings, impulses, or actions

Schizophrenia:  2 or more symptoms during a 1 month period for at least 6 months

Schizophreniform Disorder:  lasts at least 1 month but less than 6 months

Schizoaffective Disorder:  at least 2 weeks in the absence of prominent mood symptoms

·      mood disorder following childbirth, anxiety, irritability, tearfulness, “baby blues.”  If symptoms do not dissolve after 1^st 2 weeks after birth, they need to seek help and assessment for other issues.  Example:  Andrea Yeats – drowned all 5 of her children due to this depression, worsened with each birth.

ONSET of episode within 4 weeks of delivery

The extrapyramidal system can be affected in a number of ways, which are revealed in a range of extrapyramidal symptoms (EPS), also known as extrapyramidal side-effects (EPSE), such as akinesia (inability to initiate movement) and akathisia (inability to remain motionless).

Extrapyramidal symptoms (EPS) are various movement disorders such as acute dystonic reactions, pseudoparkinsonism, or akathisia suffered as a result of taking dopamine antagonists, usually antipsychotic (neuroleptic) drugs, which are often used to control psychosis. It can also be a symptom of a metabolic disease.

Extrapyramidal syndrome (EPS) is due to the blockade of dopamine receptors in the basal ganglia, leading to Parkinson-like symptoms such as slow movement (bradykinesia), stiffness, and tremor.

SSRI Overview

Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor^[1] (SSRIs) are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders.

SSRIs are believed to increase the extracellular level of the neurotransmitter serotonin by inhibiting its reuptake into the presynaptic cell, increasing the level of serotonin in the synaptic cleft available to bind to the postsynaptic receptor. They have varying degrees of selectivity for the other monoamine transporters, with pure SSRIs having only weak affinity for the noradrenaline and dopamine transporter.

SSRIs are the first class of psychotropic drugs discovered using the process called rational drug design, a process that starts with a specific biological target and then creates a molecule designed to affect it.^[2] They are the most widely prescribed antidepressants in many countries.^[2] The efficacy of SSRIs in mild or moderate cases of depression has been disputed

·      Nausea

·      Dry mouth

·      Headache

·      Nervousness, agitation or restlessness

·      Reduced sexual desire

·      Erectile dysfunction

·      Rash

·      Increased sweating

·      Weight gain

·      Drowsiness

insomina

Serotonin Reuptake inhibitors (SSRI’s)

-       Popular antidepressant; most commonly prescribed

-       Eases depression by affecting the chemical messengers (neurotransmitters) used to communicate between brain cells

-       SSRI’s block the reuptake (reabsorption) of the neurotransmitter serotonin in the brain

Bipolar I Disorders:

·      Single episode manic

·      Most recent episode hypomanic – note causes of significant distress in life areas

·      Most recent episode manic, mixed, or depressed

·      Most recent episode unspecified – note causes of significant distress in life areas

·      Mood episodes separated by periods of “normal” mood lasting at least 2 months

·      Rapid cycling occurs when 4 or more episodes are evident in 1 year

·      Seasonal pattern indicates mood episodes occurring during a particular time of the year, such as fall/early winter                                                                                     

·      General medical condition or substance use does not better explain the bipolar mood episode

·      Mood episode is distinguished from the psychotic disorders where psychotic symptoms occur in the absence of prominent mood symptoms

·      Presence (or h/o) of one or more major depressive episodes

·      Presence (or h/o) of at least 1 hypomanic episode

·      Symptoms are severe enough to affect social, work, or other important life areas

·      Rapid cycling occurs when 4 or more episodes are evident in 1 year

·      Seasonal pattern indicates mood episodes occurring during a particular time of the year, such as fall/early winter             

·      Hypomanic episodes last a minimum of 4 days

·      Major Depressive Disorder lasts at least 2 weeks

·      Presence of a manic or mixed episode precludes considering

·      Consider general medical conditions or substance use to better “explain” symptoms

·      Symptoms are not better accounted for by schizophrenia, shizophreniform disorder, delusional disorder, or psychotic disorder, NOS

·      Presence of numerous periods w/hypomanic symptoms and numerous periods with depressive symptoms that are not of the intensity of a major depressive episode

·      Symptoms are severe enough to impair social, work, or other important life areas

·      Symptoms are present for at least 2 years and during this time, the person has not been without symptoms for more than 2 months at a time

·      In children and adolescents the mood disturbance must be at least for 1 year

·      There is no major depressive episode, manic episode, or mixed episode during the initial 2 years of the disturbance (1 for children/adolescence)

·      Symptoms are not better explained by the presence of substance use, general medical conditions, or schizophrenia

·      Symptoms are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder NOS

Mood Disorder due to a general medical condition…indicate the general medical condition

Depressed / Manic / Mixed

Substance-Induced Mood Disorder, Depressed / Manic / Mixed

Mood Disorder NOS

 Major Depressive Disorder (single or recurrent)

Mild, Moderate, Severe without psychotic features

Severe with psychotic features 

Dysthymic Disorder

Depressive Disorder NOS

·      Reports depressed mood and shows 2 or more of the following: 

o   Appetite – increase or decrease

o   Sleep – patterns increase or decrease

o   Fatigue – or a low level of energy

o   Poor self-image

o   Concentration – hard to concentrate or is indecisive

o   Hopeless feelings

·      Symptoms are severe enough to impair important areas of one’s life

·      Symptoms are never absent for longer than 2 consecutive months & last for most days for 2 years or more

·      For the 1^st 2 years (or 1 for children/adolescents), the person has not experienced a major depressive episode

·      Never experienced cyclothymic disorder nor meets criteria for a manic episode, a mixed episode, or hypomanic episode

·      Disorder does not exist solely in the context of a chronic psychosis

·      Symptoms are not better explained by substance use or medical condition