Either Obessions or Compulsions:

1. At some point the person has to recognized that the obessions or compulsions are excessive or unreasonable (doesn't apply to children)
2. There is caused Marked Distress, are time comsuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational/or academic functioning, or usual social activities or relationships
3. If another Axis 1 disorder is present: the content of the o/c is not restricted to it (eg preoccupated with food in the presence of an eatting disorder.)
4. The disturbance is not due to the direct physiological effects of a substance or general medical condition.
5. Specify if with poor insight: most of the time durin the episode the person does not recognize that the O/C are excessive or unreasonable

• Treatment: Clomoprimine (Anafranil) and Exposure Therapy

**Within a month of trauma and after a month change dx to PTSD**

 A. The person has been exposed to a traumatic event in which both o the following are present:

1. the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury or a threat t othe physical intergrity of self or others

2. the person's repsonse involved intense fear, helplessness or horror

B. Either while experiencing or after experiencing the distressing event, the individual has 3 or more of the following dissocaiative symptoms:

1. subjective sense of numbing, detachment, or absence of emotional responsiveness

2. a reduction in awareness of his or her surroundings

3. derealization

4. depersonalization

5. dissociative amnesia (inability to recall an important aspect of the trauma)

C. Traumatic event is persistently reexperienced in at least one of the following ways: reccurent images, thoughts, dreams, illusions, flashbacks episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma

E. Marked symptoms of anxiety of increased arousal

F. Disturbance causes clinically significant distress or impariment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursure some necessary task, such as obtaining necessary assistance or mobilizing peronsal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance or general medical condition, is not better accounted fo by brief psychotic disorder, and is not merely an exacerbation of a preexisting Axis 1 or Axis 2 disorder.

Social Phobia

(Social Anxiety Disorder)

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted fro by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety, Body Dysmorphic Disorder, a Pervasisive Developmental Disorder, or Schizoid
Personality Disorder).
H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s Disease, or exhibiting abnormal eating behavior in Anorexia Nervosa.

• 1 year prevalence
• Treatment:
• Cognitive Restructuring:
• thoughts are hypotheses
• self-monitoring to test
• evaluate catastrophic predictions
• Exposure
• preparation
• identify safty behaviors in advance
• Medication

• Teach + practice relaxation
• imagine a pic of a spider in a magazine+ relax
• imagine touching the spider in the magazine+ relax
• imagine a spider on the TV+ relax
• imagine touching the screen+relax
• imagine a spider on the wall in the next room+ relax
• imagine a spider on the wall in the room+ relax
• imagine a spider on the floor by your chair+ relax
• imagine a spider on your shoulder through a leather jacket+ relax
• imagine a spider on your shoulder through cotton shirt+ relax
• imagine a spdier on your bare shoulder+ relax
• repeat

1. repetitive behaviors (hand washing, order, checking)  or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly
2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

Distortion in inferential thinking

• excess of inference, eg seeing a connection between people, events etc and adding meaning

Distortions in sensory perception

• excess of perception- usually hearing but also seeing, smelling, tasting, or touching something that consensus suggests is very different

1. recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. the thoughts, impulses, or images are not simply excessive worries about reallife problems
3. the person attempts to ignore or suppress such thoughts, impulses or images or to neutralize them with some other thought or action
4. the person recognizes that the obessional thoughts, impulses or images are a product of his her own mind (not imposed form without as in thought insertion)

A. The person has been exposed to a traumatic event in which both of the following were present:
1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
2. the person’s response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
2. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur
4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the event
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
1. efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. efforts to avoid activities, places, or people that arouse recollections of the trauma.
3. inability to recall an important aspect of the trauma
4. markedly diminished interest or participation in significant activities
5. feeling of detachment or estrangement from others
6. restricted range of affect (e.g., unable to have loving feelings)
7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Re-experiencing (for at least 1 month) a traumatic event accompanied by symptoms of increased arousal and avoidance of trauma cues

Specify if acute (<3 months) chronic (>3 months)

Specify if delayed onset (symptoms appear >6 months after trauma)

100,000 rapes in the US reported per year:

only 1 in 7 rapes are reported

1 in 4 women will be raped in her lifetime

1 in 2 women sexually assaulted/molested/forced

95% of rape survivors show trauma sx within 2 weeks

Typical sx are flashbacks, sleep disturbance, insomnia, startle response, and sexual dysfunction

4 to 6 years after rape:

75% of survivors say they have recovered

50% say the recovery occurred in the first 3 months

25% of have not recovered at 6 years

16% have diagnosable PTSD

• Protracted (>6 months duration) period of anxiety and worry, accompanied by multiple associated symptoms that cannont be attributable to the more focal distress of panic disorder, social phobia, obessive-compulsive disorder, or other conditions
• 1 year prevalence: 3% (2x more likely in women)

 A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

• Panic Disorder is diagnosed when a person has experienced at least two unexpected panic attacks and/or (1) develops persistent concern or worry about having further attacks; (2) changes his or her behavior to avoid or minimize such attacks
• Comorbidity of panic disorder: MDD (65%) A/SA disorders (30%) SAD (30%) GAD (25%) Specific phobia (20%) OCD (10%)

• adults generally recognize that the intense fear of animals, situations is irrational
• 1 year prevalence: 8% (would be much higher if avoidance criterion were not used)
• most common specific phobias: animals (especially snakes, rodents, birds and dogs) Insects (especially spiders and bees or hornets) heights, elevators, flying, automobile driving, water, storms, blood/injections
• Note: most were dangerous to our ancestors
• Phobias are usually learned vicariously rather than from direct experience
• Phobias treatable by systematic desensitization, flooding

• Behavior and/or mood problems within 3 months following an identifiable stressor which result in either more than expected distress and/or significant impairment in work, school, or social functioning
• mostly resolved in 6 months
• Type:
• depressed mood
• anxiety
• mixed anxiety and depression
• conduct disturbance
• mixed conduct and emotional disturbance
• unspecified
• Course:
• Acute (<6 months)
• Chronic ( >6 months)
• e.g. Adjustment Disorder with Anxiety and Depression, Acute
• Code stressor on Axis IV

on (SSRIs, tric

•Behavior therapy (Exposure +CBT) is treatment of choice

•In general, treatment is more effective on positive sx ( startle, sleep, etc) than neg sx (withdrawal, numbing, etc.) or emotion management (e.g. anger)

Medication (SSRIs, tricyclics, neuroleptic)

The earlier the better!

yclics, neuroleptic)

•Somatization Disorder (hysteria or Briquet's syndrome)--Combination of pain, gastrointestinal, sexual, and pseudoneurological symptoms

•Undifferentiated Somatoform Disorder --Unexplained physical complaints below the threshold for a diagnosis of Somatization Disorder

•Conversion Disorder (hysteria) --Unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition

•Pain Disorder --Pain is the predominant focus of clinical attention

•Hypochondriasis --Preoccupation with the fear of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms or bodily functions

•Body Dysmorphic Disorder --Preoccupation with an imagined or exaggerated defect in physical appearance

*A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment of functioning.
*Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance.
o 4 pain symptoms: a history of pain related to at least 4 different sites or functions 
o 2 gastrointestinal symptoms: a history of at least 2 gastrointestinal symptoms other than pain 
o 1 sexual symptom: a history of at least 1 sexual or reproductive symptom other than pain 
o 1 pseudoneurological symptom: a history of at least 1 symptom or deficit
suggesting a neurological condition not limited to pain
Either:
o After appropriate investigation, each of the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance OR
o When there is a related general medical condition, the physical complaints or
resulting social or occupational impairment are in excess of what would be
expected from the history, physical examination, or laboratory findings
*The symptoms are not intentionally produced or feigned.

Note: The DSM-IV distinguishes Panic Disorder with Agoraphobia

from Panic Disorder Without Agoraphobia. In the summary below, see

criterion B:

A. Both (1) and (2):

1. Recurrent unexpected Panic Attacks

2. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:

a. Persistent concern about having additional attacks

b. Worry about the implications of the attack or its consequences

(e.g., losing control, having a heart attack, “going crazy”)

c. A significant change in behavior related to the attacks

B. Absence of Agoraphobia / Presence of Agoraphobia.

C. The Panic attacks are not due to the direct physiological effects of a

substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., on exposure to dirt in someone with an obsession about contamination), Post-Traumatic Stress Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives).

Diagnostic Criteria for a Panic Attack

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

• palpitations, pounding heart, or  accelerated HR

• sweating

• trembling or shaking

• sensations of shortness of breath  or smothering

• feeling of choking

• chest pain or discomfort

• nausea or abdominal distress

• feeling dizzy, unsteady, lightheaded,  or faint

• derealization or depersonalization

• fear of losing control or going crazy

• fear of dying

• paresthesias (numbing or tingling sensations)

• chills or hot flushes

 A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Note: Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.)

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

Note: In children, consider failure to make expected weight gains.

4. Insomnia or hypersomnia nearly every day

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year:
B. Presence, while depressed, of two (or more) of the following:
1. poor appetite or overeating
2. insomnia or hypersomnia
3. low energy or fatigue
4. low self-esteem
5. poor concentration or difficulty making decisions
6. feelings of hopelessness

 Mania and Depression

One or more Manic or Mixed episodes, usually accompanied by Major Depressive Episodes

 Hypomania and Depression

One or more Major Depressive Episodes accompanied by at least one Hypomanic Episodes

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary):
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

A. The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period:

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood:
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Schizophreniform Disorder

•Criterion A: Meets Criterion A for schizophrenia

•Does not meet 6 month criterion for schizophrenia

•Most (70%) people diagnosed schizophreniform are eventually diagnosed schizophrenic or schizoaffective

•Consider Brief Psychotic Disorder (< 1 mo)

Diagnostic Criteria for Schizophrenia

•Criterion A:  One month of at least two psychotic symptoms

•Lowering of social or occupational  functioning

•6-month duration from onset

•Consider schizoaffective & mood disorder

•r/o general medical & substance use

•r/o pervasive developmental disorder

Schizo

Schizophrenia Subtypes
(will probably be ommitted from DSM 5)

phrenia Subtypes
(will probably be ommitted from DSM 5)

•Catatonic

•Repetitive motor sx

•Disorganized

•Disorganized speech or behavior; prominent negative sx, with poor ADLs as a result; earlier term: hebephrenic

•Paranoid

•Auditory hallucinations, suspicion, but cognitive and affect functions preserved

•Undifferentiated

•Psychotic sx but does not meet criteria for C-D-P types

•Residual

•Not currently psychotic—residual phase after active phase

Schizoaffective Disorder

•Criterion A:  Meets Criterion A for schizophrenia and criteria for a major mood disorder

•Also requires psychotic symptoms for  2 weeks in absence of mood symptoms

•Two sub-types: (1) Depressive (2) Bipolar

•Consider duration of mood symptoms relative to psychotic symptoms

Delusional Disorder

•Criterion A: At least one non-bizarre delusion for a month

•Non-bizarre = plausible but unlikely (e.g.: My mother survived the Titanic)

•Has never met criteria for schizophrenia; if any hallucinations, not prominent

Hypomania and Dysthymia

2 years or more of hypomanic and depressive symptoms that do not meet criteria for Manis or Major Depressive Episodes

•Crisis intervention

§medical intervention necessary if full-blown

§lithium likely to be effective

•Individual, marital/family therapy once stable

§Medication, side effects monitoring

§Cognitive therapy found effective at increasing medication compliance

•Psychoeducation for consumer, family

Generic Social Work Treatment of Depression

•Establish social support

•Establish relationship with the healthy part of personality

•Educate consumer about treatment

•Target levels of depression

§Observable symptoms: fatigue, crying, suicidal ideas & behavior (meds)

§Motivational disturbance: avoidance of activity, isolation (social therapy)

§Cognition and belief systems (cognitive therapy)

Generic Principles of Social Work Practice in Depression

•r/o suicide (MMO)

•r/o substance abuse

•r/o mania, hypomania, psychosis

•r/o organicity (to the extent possible)

•Engage support system (if posssible)

§SS strong & constructive => psychotherapy

§SS weak/destructive => separate, control, treat sx

§SS not available => transitional support until engaged

§SS unused => engage

•Decrease guilt

•Increase hope

Four Effective Treatments for Depression

•Anti-depressants [TCA, HCA, SSRI]

§65% effective, fast response, high relapse

•Electro-convulsive Therapy [ECT]

§75% effective, fast response, high relapse

•Interpersonal Therapy [IPT]

§70% effective, slower response, modest relapse

•Cognitive Therapy [CBT]

§70% effective, slower response, modest relapse

Meds Treatment of
Bipolar Depression

•Depressive phase of bipolar is different than unipolar depression

§less responsive to tx than the manic phase

§Antidepressants may precipitate a manic episode or rapid cycling

§usually treated w/mood stabilizer rather than antidepressants

(1) Recognize automatic thoughts (AT)

(2) Dispute ATs

ask client for evidence to support every AT

(3) Reattribution (re-storying)

making new explanations

(4) Thought stopping & thought substitution

Learning how to distract from depressing ATs and substitute more accurate but less depressing thoughts

(5) Challenge underlying schema & assumptions

I cant live without love

I have to be married

I have to do everything perfectly

Everyone has to like me

There is a solution for every problem

CBT works better on moderate than severe depression

CBT works better with educated people