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Neurodevelopmental Disorders - are a group of conditions with onset in the developmental period often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning. Intellectual Disabilities Intellectual Disability (Intellectual Developmental Disorder) is a disorder with onset during the developmental period that includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. A. Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience. B. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life. C. Onset of intellectual and adaptive deficits during the developmental period. Specifiers : Mild – can live independently; intermittent support needed Moderate – moderate levels of support; limited support needed in daily situations Severe – requires daily assistance; extensive support needed Profound – requires 24-hour care; pervasive support needed for every aspect
- Onset: developmental period
- Includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.
- Difficulties with day-to-day activities to an extent that reflects both severity of their cognitive deficits and the type and amount of assistance their receive.
- Difficulties in conceptual, social, and judgement.
- Causes: deprivation, abuse, neglect, exposure to disease or drugs during pre- natal, difficulties during labor and delivery, infections, and head injury.
- Phenylketonuria (amino acids), Lesch-Nyhan Syndrome (women who carry fragile X syndrome commonly display mild to severe learning), Down Syndrome, Fragile X Syndrome (abnormality of the X chromosome (affects males).
- Generally nonprogressive, there are period of worsening, then stabilization, and in others progressive of intellectual function in varying degrees.
- Generally lifelong, although severity changes over time.
- Major Neurocognitive Disorder may co-occur with IDD.
- Components of intellectual functioning; verbal comprehension, working memory, perceptual reasoning, quantitative reasoning, abstract thought, cognitive efficacy. Global Developmental Delay This diagnosis is reserved for individuals under the age of 5 years when the clinical severity level cannot be reliably assessed during early childhood. This category is diagnosed when an individual fails to meet expected developmental milestones in several areas of intellectual functioning, and applies to individuals who are unable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in standardized testing. This category requires reassessment after a period of time. Unspecified Intellectual Disability (Intellectual Developemental Disorders) This category is reserved for individuals over the age of 5 years when assessment of the degree of intellectual disability (intellectual developmental disorder) by means of locally available procedures is rendered difficult or impossible because of associated sensory or physical impairments, as in blindness or prelingual deafness; locomotor disability; or presence of severe problem behaviors or co-occurring mental disorder. This category should only be used in exceptional circumstances and requires reassessment after a period of time. Communication Disorders Disorders of communication include deficits in language, speech, and communication.
- Speech is the expressive production of sounds and includes an individual's articulation, fluency, voice, and resonance quality.
- Language includes the form, function, and use of a conventional system of symbols (i.e., spoken words, sign language, written words, pictures) in a rule- governed manner for communication.
- Communication includes any verbal or nonverbal behavior (whether intentional or unintentional) that influences the behavior, ideas, or attitudes of another individual. Language Disorder A. Persistent difficulties in the acquisition and use of language across modalities (i.e., spoken, written, sign language, or other) due to deficits in comprehension or production that include the following:
- Reduced vocabulary (word knowledge and use).
- Limited sentence structure (ability to put words and word endings together to form sentences based on the rules of grammar and morphology).
- Impairments in discourse (ability to use vocabulary and connect sentences to explain or describe a topic or series of events or have a conversation). B. Language abilities are substantially and quantifiably below those expected for age, resulting in functional limitations in effective communication, social participation, academic achievement, or occupational performance, individually or in any combination. C. Onset of symptoms is in the early developmental period. D. The difficulties are not attributable to hearing or other sensory impairment, motor dysfunction, or another medical or neurological condition and are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay.
- Difficulties in acquisition and use of language modalities due to deficits in comprehension and production.
- Reduced vocab, limited sentence structure, impairments in discourse.
- Regional, social, or cultural/ethnic variations must be considered when an individual is being assessed.
- Declines in critical social communication behavior during the first two years of life are evident in most children with autism spectrum disorder, thus, it must be not confused with language disorder.
- Expressive ability refers to the production of vocal, gestural, or verbal signals, while receptive ability refers to the process of receiving and comprehending language messages. Speech Sound Disorder A. Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication of messages. B. The disturbance causes limitations in effective communication that interfere with social participation, academic achievement, or occupational performance, individually or in any combination. C. Onset of symptoms is in the early developmental period. D. The difficulties are not attributable to congenital or acquired conditions, such as cerebral palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or other medical or neurological conditions.
- Speech sound production describes the clear articulation of the phonemes (i.e., individual sounds) that in combination make up spoken words. Speech sound production requires both the phonological knowledge of speech sounds and the ability to coordinate the movements of the articulators (i.e., the jaw, tongue, and lips,) with breathing and vocalizing for speech.
- Among typically developing children at age 4 years, overall speech should be intelligible, whereas at age 2 years, only 50% may be understandable.
- Verbal dyspraxia is a term also used for speech production problems.
- Children’s progression in mastering speech sound production should result in most intelligible speech by age 3 years.
- The most frequently misarticulated sounds also tend to be learned later, leading them to be called the '' late eight " (l, r, s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by itself could be considered within normal limits up to age 8 years.
- Continue to use immature phonological simplification processes past the age when most children can produce words clearly.
- Respond well to treatment, and speech difficulties improve over time.
- When LD is also present, Speech Disorder has poorer prognosis and may be associated with SLD.
- Selective Mutism may develop in children with Speech Disorder because of their embarrassment about their impairments, but many children with SM exhibit normal speech in “safe” settings. Childhood-Onset Fluency Disorder (Stuttering) A. Disturbances in the normal fluency and time patterning of speech that are inappropriate for the individual’s age and language skills, persist over time, and are characterized by frequent and marked occurrences of one (or more) of the following:
- Sound and syllable repetitions.
- Sound prolongations of consonants as well as vowels.
- Broken words (e.g., pauses within a word).
- Audible or silent blocking (filled or unfilled pauses in speech).
- Circumlocutions (word substitutions to avoid problematic words).
- Words produced with an excess of physical tension.
- Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”). B. The disturbance causes anxiety about speaking or limitations in effective communication, social participation, or academic or occupational performance, individually or in any combination. C. The onset of symptoms is in the early developmental period. (Note: Later-onset cases are diagnosed as adult-onset fluency disorder.) D. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency associated with neurological insult (e.g., stroke, tumor, trauma), or another medical condition and is not better explained by another mental disorder.
- Disturbances in normal fluency and time patterning of speech that are inappropriate for the individual’s age and language skills.
- Occurs by age 6 for 80%-90% of affected individuals, with age at onset ranging from 2 to 7 years.
- Can be insidious or more sudden.
- When the speech dysfluencies are in excess of those usually associated with these problems, a diagnosis of childhood-onset fluency disorder may be made.
- Slower reading rates may not accurately reflect the actual reading ability of children who stutter. Social (Pragmatic) Communication Disorder A. Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all the following:
- Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.
- Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding use of overly formal language.
- Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.
- Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral or ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation). B. The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. C. The onset of the symptoms is in the early developmental period (but deficits may not become fully manifest until social communication demands exceed limited capacities).
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D. The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global developmental delay, or another mental disorder.
- Difficulties in the social use of verbal and nonverbal communication.
- Deficits in using communication for social purposes in a manner that is appropriate for the social context.
- Difficulties in following the rules of conversating and do not understand metaphors, etc.
- Current symptoms or developmental history fails to reveal evidence that could meet the restrictive/repetitive patterns of behavior, interests, or activities of AS.
- Rare among children younger than 4 years.
- By age 4 or 5 years, most children should possess adequate speech and language abilities to permit identification of specific deficits in social communication.
- A diagnosis of social (pragmatic) communication disorder should be considered only if the current symptoms or developmental history fails to reveal evidence of symptoms that meet the diagnostic criteria for restricted/repetitive patterns of behavior, interests, or activities of ASD.
- A separate diagnosis of SCD in IDD or GDD unless social communication deficits are clearly excess of intellectual limitations. Unspecified Communication Disorder This category applies to presentations in which symptoms characteristic of communication disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for communication disorder or for any of the disorders in the neurodevelopmental disorders diagnostic class. The unspecified communication disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for communication disorder or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis. Autism Spectrum Disorder Autism spectrum disorder is characterized by persistent deficits in social communication and social interaction across multiple contexts. A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive):
- Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.
- Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures: to a total lack of facial expressions and nonverbal communication.
- Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity : Severity is based on social communication impairments and restricted, repetitive patterns of behavior. B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive):
- Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).
- Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).
- Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
- Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Specify current severity : Severity is based on social communication impairments and restricted, repetitive patterns of behavior (see Table 2). C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life). D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level Specifiers : Current severity With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known genetic or other medical condition or environmental factor Associated with a neurodevelopmental, mental, or behavioral problem With catatonia Levels : Level 1 - requiring support Level 2 - requiring substantial support Level 3 - requiring very substantial support
- Manifestations of the disorder also vary greatly depending on the severity of the autistic condition, developmental level, and chronological age; hence, the term spectrum.
- First become evident in early childhood, with some cases presenting a lack of interest in social interaction in the first year of life.
- Symptoms recognized during the second year of life.
- Two major characteristics: ✓ Impairments in social communication and social interaction. ▪ Failure to develop age-appropriate social relationships. ▪ Problems with social reciprocity, nonverbal communication, and initiating and maintaining social relationships. ▪ Inability to engage in Joint Attention. ✓ Restricted, repetitive patterns of behavior, interests, or activities. ▪ Extremely upset about small changes (maintenance of sameness)
- Associated with declines in critical social and communication behaviors in the first 2 years of life.
- Not degenerative disorder, and it is typical for learning and compensation to continue throughout life.
- Individuals with lower levels of impairment may be better able to function independently.
- The developmental course and absence of restrictive, repetitive behaviors and unusual interests in ADHD help in differentiating ASD and ADHD.
- A concurrent diagnosis of ADHD should be considered when attentional difficulties or hyperactivity exceeds that typically seen in individuals of comparable mental age.
- ADHD is one of the most common comorbidities in ASD.
- A diagnosis of ASD in individual with IDD is appropriate when social communication and interaction are significantly impaired relative to the developmental level of the individual’s nonverbal skills.
- IDD is appropriate diagnosis when there is no apparent discrepancy between the level of social communicative skills and other intellectual skills.
- The diagnosis of ASD supersedes that of social communication disorder whenever the criteria for ASD are met, and care should be taken to enquire carefully regarding past or current restricted/repetitive behavior.
- Rett Disorder – genetic condition that affects mostly females and is characterized by hand wringing and poor coordination.
- Clear genetic component.
- Evidence of brain damage combined with psychosocial influences.
- Treatment: Behavioral Focus, Inclusive Schooling, Medication. Attention-Deficit/Hyperactivity Disorder
- Inattention and disorganization entail inability to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level.
- Hyperactivity-impulsivity entails overactivity, fidgeting, inability to stay seated, intruding into other people's activities, and inability to wait—symptoms that are excessive for age or developmental level. A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):
- Inattention : Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining ocused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). h. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).
- Hyperactivity and Impulsivity : Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: a. Often fidgets with or taps hands or feet or squirms in seat. b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
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Motor Disorders Developmental Coordination Disorder A. The acquisition and execution of coordinated motor skills is substantially below that expected given the individual’s chronological age and opportunity for skill learning and use. Difficulties are manifested as clumsiness (e.g., dropping or bumping into objects) as well as slowness and inaccuracy of performance of motor skills (e.g., catching an object, using scissors or cutlery, handwriting, riding a bike, or participating in sports). B. The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (e.g., self-care and self- maintenance) and impacts academic/school productivity, prevocational and vocational activities, leisure, and play. C. Onset of symptoms is in the early developmental period. D. The motor skills deficits are not better explained by intellectual disability (Intellectual developmental disorder) or visual impairment and are not attributable to a neurological condition affecting movement (e.g., cerebral palsy, muscular dystrophy, degenerative disorder).
- Developmental coordination disorder is typically not diagnosed before age 5 years because there is considerable variation in the age at acquisition of many motor skills or a lack of stability of measurement in early childhood (e.g., some children catch up) or because other causes of motor delay may not have fully manifested.
- Other terms used to describe developmental coordination disorder include childhood dyspraxia, specific developmental disorder of motor function, and clumsy child syndrome.
- The course of developmental coordination disorder is variable but stable at least to 1-year and 2 - year follow-up.
- Delayed motor milestones may be the first signs.
- Onset: early childhood
- If criteria for both ADHD and DCD are met, both can be given.
- Acquisition and execution of coordinated motor skills are below expected given the chronological age.
- Clumsiness, slowness, and inaccuracy of performance of motor skills. Stereotypic Movement Disorder A. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body). B. The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury. C. Onset is in the early developmental period. D. The repetitive motor behavior is not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessive-compulsive disorder). Specify if : With self-injurious behavior (or behavior that would result in an injury if preventive measures were not used) Without self-injurious behavior Specify if : Associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual disability [intellectual developmental disorder], intrauterine alcohol exposure) Specify current severity : Mild : Symptoms are easily suppressed by sensory stimulus or distraction. Moderate : Symptoms require explicit protective measures and behavioral modification. Severe : Continuous monitoring and protective measures are required to prevent serious injury.
- Typically begins within the first 3 years of life.
- Onset of complex motor stereotypies may be in infancy or later in the developmental period.
- Repetitive, seemingly driven, and apparently purposeless motor behavior.
- May result in self-injury. Tic Disorders Tourette’s Disorder A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis). Persistent (Chronic) Motor or Vocal Disorder A. Single or multiple motor or vocal tics have been present during the illness, but not both motor and vocal. B. The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset. C. Onset is before age 18 years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis). E. Criteria have never been met for Tourette’s disorder. Specify if : With motor tics only With vocal tics only Provisional Tic Disorder A. Single or multiple motor and/or vocal tics. B. The tics have been present for less than 1 year since first tic onset. C. Onset is before age 18 years. Typically with an average age at onset between 4 and 6 years, and with the incidence of new-onset tic disorders decreasing in the teen years. D. The disturbance is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., Huntington’s disease, postviral encephalitis). E. Criteria have never been met for Tourette’s disorder or persistent (chronic) motor or vocal tic disorder. The tic disorders are hierarchical in order ; i. Tourette's disorder, ii. followed by persistent [chronic] motor or vocal tic disorder, iii. followed by provisional tic disorder, iv. followed by the other specified and unspecified tic disorders. Such that once a tic disorder at one level of the hierarchy is diagnosed, a lower hierarchy diagnosis cannot be made. Tics can be either simple or complex : Simple motor tics are of short duration (i.e., milliseconds) and can include eye blinking, shoulder shrugging, and extension of the extremities. Complex motor tics are of longer duration (i.e., seconds) and often include a combination of simple tics such as simultaneous head turning and shoulder shrugging. Complex tics can appear purposeful, such as a tic-like sexual or obscene gesture ( copropraxia ) or a tic-like imitation of someone else's movements ( echopraxia ). Similarly, complex vocal tics include repeating one's own sounds or words (palilalia), repeating the last-heard word or phrase ( echolalia ), or uttering socially unacceptable words, including obscenities, or ethnic, racial, or religious slurs ( coprolalia ).
- Tic – sudden, rapid, recurrent, non-rhythmicmotor movement or vocalization
- Tourette’s – both multiple motor and one or more vocal tics (more than 1 year)
- Persistent – single or multiple motor or vocal tics but not both (more than 1 year)
- Provisional – single or multiple motor and/or vocal tics (less than 1 year)
- Onset: typically between ages 4 and 6 years
- Motor Stereotypies are defined as involuntary rhythmic, repetitive, predictable movements that appear purposeful but serve no obvious adaptive function; often self-soothing or pleasurable and stop with distraction
- Chorea – rapid, random, continual, abrupt, irregular, unpredictable, nonstereotyped actions that are usually bilateral and affect all parts of the body
- Dystonia – simultaneous sustained contraction of both agonist and antagonist muscles, resulting in a distorted posture or movements of the parts of the body. Other Specified Tic Disorders This category applies to presentations in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for a tic disorder or any of the disorders in the neurodevelopmental disorders diagnostic class. The other specified tic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for a tic disorder or any specific neurodevelopmental disorder. This is done by recording “other specified tic disorder” followed by the specific reason (e.g., “with onset after age 18 years”). Unspecified Tic Disorders This category applies to presentations in which symptoms characteristic of a tic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for a tic disorder or for any of the disorders in the neurodevelopmental disorders diagnostic class. The unspecified tic disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a tic disorder or for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis. Other Specified Neurodevelopmental Disorder This category applies to presentations in which symptoms characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the neurodevelopmental disorders diagnostic class. The other specified neurodevelopmental disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific neurodevelopmental disorder. This is done by recording “other specified neurodevelopmental disorder” followed by the specific reason (e.g., “neurodevelopmental disorder associated with prenatal alcohol exposure”). An example of a presentation that can be specified using the “other specified” designation is the following: Neurodevelopmental disorder associated with prenatal alcohol exposure : Neurodevelopmental disorder associated with prenatal alcohol exposure is characterized by a range of developmental disabilities following exposure to alcohol in utero. Other Unspecified Neurodevelopmental Disorder This category applies to presentations in which symptoms characteristic of a neurodevelopmental disorder that cause impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the neurodevelopmental disorders diagnostic class. The unspecified neurodevelopmental disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific neurodevelopmental disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings) Disruptive, Impulse-Control, and Conduct Disorders include conditions involving problems in the self-control of emotions and behaviors. May also involve problems in emotional and/or behavioral regulation, the disorders in this chapter are unique in that these problems are manifested in behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures. The underlying causes of the
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problems in the self-control of emotions and behaviors can vary greatly across the disorders in this chapter and among individuals within a given diagnostic category. Oppositional Defiant Disorder A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling. Angry/Irritable Mood
- Often loses temper.
- Is often touchy or easily annoyed.
- Is often angry and resentful. Argumentative/Defiant Behavior
- Often argues with authority figures or, for children and adolescents, with adults.
- Often actively defies or refuses to comply with requests from authority figures or with rules.
- Often deliberately annoys others.
- Often blames others for his or her mistakes or misbehavior. Vindictiveness
- Has been spiteful or vindictive at least twice within the past 6 months. Note : The persistence and frequency of these behaviors should be used to distinguish a behavior that is within normal limits from a behavior that is symptomatic. For children younger than 5 years, the behavior should occur on most days for a period of at least 6 months unless otherwise noted (Criterion A8). For individuals 5 years or older, the behavior should occur at least once per week for at least 6 months, unless othenwise noted (Criterion AS). While these frequency criteria provide guidance on a minimal level of frequency to define symptoms, other factors should also be considered, such as whether the frequency and intensity of the behaviors are outside a range that is normative for the individual’s developmental level, gender, and culture. B. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues), or it impacts negatively on social, educational, occupational, or other important areas of functioning. C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder. Specify current severity : Mild : Symptoms are confined to only one setting (e.g., at home, at school, at work, withpeers). Moderate : Some symptoms are present in at least two settings. Severe : Some symptoms are present in three or more settings. It is not uncommon for individuals with oppositional defiant disorder to show symptoms only at home and only with family members. However, the pervasiveness of the symptoms is an indicator of the severity of the disorder.
- It’s common for individuals with oppositional defiant disorder to show the behavioral features of the disorder without problems of negative mood. However, individuals with the disorder who show the angry/irritable mood symptoms typically show the behavioral features as well.
- Usually appear during preschool years and rarely later than adolescence.
- Angry irritable mood, argumentative/defiant behavior against authority figure for at least 6 months.
- Annoys others.
- Blames others for his/her mistakes.
- Two of the most co-occurring conditions with ODD are ADHD and CD.
- Often precedes the development of conduct disorder, common in children with the childhood-onset subtype.
- Conveys risk for the development of anxiety disorders and MDD.
- Increased risk for a number of problems in adjustment as adults.
- Less severe than CD and do not include aggression towards people, property (IED).
- Co-morbid with ADHD
- Diagnosis should not be made if the symptoms occur exclusively during the course of a mood disorder.
- If criteria for DMDD are met, then DMDD is given even if all criteria for ODD are met. Intermittent Explosive Disorder A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following;
- Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
- Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period. B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors. C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective (e.g., money, power, intimidation). D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences. E. Chronological age is at least 6 years (or equivalent developmental level). F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). For children ages 6 - 18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis. Note : This diagnosis can be made in addition to the diagnosis of attention- deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention.
- Behavioral outburst, failure to control aggressive impulses.
- Verbal aggression, physical aggression twice weekly for a period of 3 months.
- At least 6 years of age.
- Quite common regardless of the presence of ADHD or other disruptive, impulse-control, and conduct disorders.
- Depressive disorders, anxiety disorders, and substance use disorders are associated.
- Presence of serotogenic abnormalities, globally and in the brain, specifically in areas of limbic system and orbitofrontal cortex.
- Amygdala responses to anger stimuli are greater.
- Volume of gray matter in several frontolimbic regions is reduced.
- Also, should not be made in children and adolescents ages 6-18 years, when the impulsive aggressive outbursts occur in the context of an adjustment disorder.
- A diagnosis of DMDD can only be given when the onset of recurrent, problematic, impulsive aggressive outburst is before age of 10 years.
- A diagnosis of DMDD should be made for the first time after 18 years.
- Aggression in ODD is typically characterized by temper tantrums and verbal arguments with authority figures, whereas IED are in response to a broader array of provocation and include physical assault.
- Co-morbid with depressive disorders, anxiety disorders, PTSD, Bulimia, Binge- eating, and substance use disorder. Conduct Disorder A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals
- Often bullies, threatens, or intimidates others.
- Often initiates physical fights.
- Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
- Has been physically cruel to people.
- Has been physically cruel to animals.
- Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
- Has forced someone into sexual activity. Destruction of Property
- Has deliberately engaged in fire setting with the intention of causing serious damage.
- Has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or Theft
- Has broken into someone else’s house, building, or car.
- Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
- Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering: forgery). Serious Violations of Rules
- Often stays out at night despite parental prohibitions, beginning before age 13 years.
- Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
- Is often truant from school, beginning before age 13 years. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. Specify whether : Childhood-onset type : Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years. Adolescent-onset type : Individuals show no symptom characteristic of conduct disorder prior to age 10 years. Unspecified onset : Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years. Specify if : With limited prosocial emotions : To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers). Lack of remorse or guilt : Does not feel bad or guilty when he or she does some thing wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.
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h. Ictal Hallucination – associated with temporal lobe foci. i. Hypnopompic Hallucinations – happens when waking up.
- Most active part during Hallucination is Broca’s Area (speech production).
- Negative Symptoms a. Avolition – inability to initiate and persist activities. b. Anhedonia – lack of pleasure c. Asociality – lack of interest in social interactions. d. Flat Affect/Affective Flattening – do not show emotions when you would normally expect them to.
- Disorganized Symptoms
- Disorganized Speech – individual may switch from one topic to another ( derailment or loose associations ) or answers to questions may be related or completely unrelated ( tangentiality ). a. Circumstantiality : excessive and irrelevant detail in descriptions with the person eventually making his/her point. "Kumuha ako ng Koko Crunch sa sm, katabi ng honey gold flakes, nasa taas niya yung kellogs, color green yung milo... masarap yung Koko Crunch." b. Concrete Thinking : unable to abstract and speaks in concrete, literal terms. Kapag sinabihan mo siya ng "Break a leg", iisipin niya na babaliin niya dapat ang legs niya. c. Clang Associations : are groups of words chosen because of the catchy way they sound, not because of what they mean. "Gusto ko ng arrozcaldo, na apurado pero bugbog sarado na may champorado at biglang dehado." d. Loose Association : a loose connection between thoughts that are often unrelated. "Umuwi ako ng probinsya. Favorite ko ang Speak Now TV. Ay! Malamig pala sa North Pole. Eto nga pala anak ko. Ang sakit mo naman sa puso." e. Neologism : creating a new word meaning only to that person. “Lathyzoid. Oh, hindi mo alam meaning diba? that's the point.” f. Word Salad : combination of words that have no meaning. "Mine enchanted why sparks fly grow superman."
- Inappropriate Affect – laughing or crying at improper times.
- Grossly Disorganized or abnormal motor behavior – childlike silliness to unpredictable agitation.
- Neologisms – construction of new words in order to communicate with schizophrenics thoughts.
- More severe symptoms of schizophrenia first occur in late adolescence or early adulthood.
- Prodromal Stage – 1 - 2 year period before the serious symptoms occur but when less severe yet unusual behaviors start to show themselves.
- Schizophrenia is partially the result of excessive stimulation of striatal dopamine d2 receptors.
- It appears that several brain sites are implicated in the cognitive dysfunction observed among people with schizophrenia, especially prefrontal cortex, various related cortical regions and subcortical circuits, including thalamus and the striatum.
- Schizophrenogenic Mother – used for a time to describe a mother whose cold, dominant, and rejecting nature was thought to cause schizophrenia in her children.
- Double bind communication – used to portray communication style that produced conflicting messages, which caused schizophrenia to develop.
- Families with high expressed emotion view the symptoms of schizophrenia as controllable and that the hostility arises when family members think that patients just do not want help themselves. Schizotypal (Personality) Disorder Criteria and text for schizotypal personality disorder can be found in the chapter "Personality Disorders." Delusional Disorder A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note : Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder Specify whether : Erotomanic type : This subtype applies when the central theme of the delusion is that another person is in love with the individual. Grandiose type : This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery. Jealous type : This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful. Persecutory type : This subtype applies when the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Somatic type : This subtype applies when the central theme of the delusion involves bodily functions or sensations. Mixed type : This subtype applies when no one delusional theme predominates. Unspecified type : This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component). Specify if : With bizarre content : Delusions are deemed bizarre if they are clearly implausible, not understandable, and not derived from ordinary life experiences (e.g., an individual’s belief that a stranger has removed his or her internal organs and replaced them with someone else’s organs without leaving any wounds or scars). Specify if : The following course specifiers are only to be used after a 1-year duration of the disorder: First episode, currently in acute episode : First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled. First episode, currently in partial remission : Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled. First episode, currently in full remission : Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present. Multiple episodes, currently in acute episode Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous : Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course. Unspecified Specify current severity: Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician- Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”) Note : Diagnosis of delusional disorder can be made without using this severity specifier.
- One or more delusions for at least 1 month.
- Persistent belief that is contrary to the reality in the absence of other characteristics of schizophrenia.
- Tend not to have flat affect, anhedonia, or other negative symptoms.
- Socially isolated due to being suspicious.
- Shared Psychotic Disorder ( Folie a Deux ): condition in which an individual develops delusions simply as a result of a close relationship with a delusional individual.
- Erotomanic, Grandiose, Jealous, Persecutory, Somatic, Mixed, Unspecified
- Functioning is better than what is observed in Schizophrenia.
- Eventually develop schizophrenia.
- Absence of active phase of schizophrenia ( Attenuated Psychosis Syndrome ) Brief Psychotic Disorder A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):
- Delusions.
- Hallucinations.
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior- marked decrease in reactivity to the environment. Note : Do not include a symptom if it is a culturally sanctioned response. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Specify if : With marked stressor (s) (brief reactive psychosis): If symptoms occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture. Without marked stressor( s): If symptoms do not occur in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the individual’s culture. With postpartum onset : If onset is during pregnancy or within 4 weeks postpartum. Specify if : With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition) Coding note : Use additional code 293.89 (F06.1) catatonia associated with brief psychotic disorder to indicate the presence of the comorbid catatonia. Specify current severity : Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician- Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”) Note : Diagnosis of brief psychotic disorder can be made without using this severity specifier.
- Presence of one of the following: delusions, hallucinations, disorganized speech, catatonic behavior for at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.
- Typically experience emotional turmoil or overwhelming confusion.
- Can experience relapse.
- If psychotic symptoms persist for at least 1 day in PD, an additional diagnosis of Brief Psychotic Disorder may be appropriate.
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Schizophreniform Disorder A. Two (or more) of the following, each present for a significant portion of time during a 1 - month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
- Delusions.
- Hallucinations.
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (i.e., diminished emotional expression or avolition). B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “ provisional .” C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Specify if : With good prognostic features : This specifier requires the presence of at least two of the following features: onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity: good premorbid social and occupational functioning; and absence of blunted or flat affect. Without good prognostic features : This specifier is applied if two or more of the above features have not been present. Specify current severity : Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician- Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”) Note : Diagnosis of schizophreniform disorder can be made without using this severity specifier.
- Two or more of the following, present during a 1-month period: delusions, hallucinations, disorganized speech, catatonic behavior, negative symptoms.
- At least 1 month BUT less than 6 months.
- Development similar to schizophrenia. Schizophrenia A. Two (or more) of the following, each present for a significant portion of time during a 1 - month period (or less if successfully treated). At least one of these must be (1 ), (2), or (3):
- Delusions.
- Hallucinations.
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (i.e., diminished emotional expression or avolition). B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). Specify if : The following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria. First episode, currently in acute episode : First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled. First episode, currently in partial remission : Partial remission is a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled. First episode, currently in full remission : Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present. Multiple episodes, currently in acute episode : Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse). Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous : Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course. Unspecified Specify if : With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition). Coding note : Use additional code 293.89 (F06.1) catatonia associated with schizophrenia to indicate the presence of the comorbid catatonia. Specify current severity : Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician- Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”) Note : Diagnosis of schizophrenia can be made without using this severity specifier.
- Two or more of the following, present during 1-month period: delusions, hallucinations, disorganized speech, catatonic behavior, negative symptoms.
- Disturbance in one or more major areas.
- At least 6 months
- Abrupt or insidious
- Prognosis is influenced both by duration and by severity of illness and gender.
- Possible reduced psychotic experience during late life.
- Too much use of regression. Schizoaffective Disorder A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note : The major depressive episode must include Criterion A1: Depressed mood. B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Specify whether : Bipolar type : This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur. Depressive type : This subtype applies if only major depressive episodes are part of the presentation. Specify if : With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 119-120, for definition). Coding note : Use additional code 293.89 (F06.1) catatonia associated with schizoaffective disorder to indicate the presence of the comorbid catatonia. Specify if : The following course specifiers are only to be used after a 1 - year duration of the disorder and if they are not in contradiction to the diagnostic course criteria. First episode, currently in acute episode : First manifestation of the disorder meeting the defining diagnostic symptom and time criteria. An acute episode is a time period in which the symptom criteria are fulfilled. First episode, currently in partial remission : Partial remission is a time period during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled. First episode, currently in full remission : Full remission is a period of time after a previous episode during which no disorder-specific symptoms are present. Multiple episodes, currently in acute episode : Multiple episodes may be determined after a minimum of two episodes (i.e., after a first episode, a remission and a minimum of one relapse). Multiple episodes, currently in partial remission Multiple episodes, currently in full remission Continuous : Symptoms fulfilling the diagnostic symptom criteria of the disorder are remaining for the majority of the illness course, with subthreshold symptom periods being very brief relative to the overall course. Unspecified Specify current severity : Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe). (See Clinician- Rated Dimensions of Psychosis Symptom Severity in the chapter “Assessment Measures.”) Note : Diagnosis of schizoaffective disorder can be made without using this severity specifier.
- Major mood episode + delusions or hallucinations for 2 or more weeks.
- Some individuals tend to change diagnosis into mood disorder or to schizophrenia over time.
- Anosognosia (poor insight) common in schizoaffective but less severe than in schizophrenia. Substance/Medication-Induced Psychotic Disorder A. Presence of one or both of the following symptoms:
- Delusions.
- Hallucinations. B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2):
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spectrum and other psychotic disorder” followed by the specific reason (e.g., “persistent auditory hallucinations”). Examples of presentations that can be specified using the “other specified” designation include the following:
- Persistent auditory hallucinations occurring in the absence of any other features.
- Deiusions with significant overlapping mood episodes : This includes persistent delusions with periods of overlapping mood episodes that are present for a substantial portion of the delusional disturbance (such that the criterion stipulating only brief mood disturbance in delusional disorder is not met).
- Attenuated psychiosis syndrome : This syndrome is characterized by psychotic-like symptoms that are below a threshold for full psychosis (e.g., the symptoms are less severe and more transient, and insight is relatively maintained).
- Delusional symptoms in partner of individuai with delusional disorder : In the context of a relationship, the delusional material from the dominant partner provides content for delusional belief by the individual who may not otherwise entirely meet criteria for delusional disorder. Other Unspecified Schizophrenia Spectrum and Other Psychotic Disorder This category applies to presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the schizophrenia spectrum and other psychotic disorders diagnostic class. The unspecified schizophrenia spectrum and other psychotic disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific schizophrenia spectrum and other psychotic disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). Personality Disorders A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.
- Paranoid personality disorder is a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent.
- Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.
- Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.
- Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others.
- Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
- Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.
- Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.
- Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
- Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.
- Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism, and control.
- Personality change due to another medical conditio n is a persistent personality disturbance that is judged to be due to the direct physiological effects of a medical condition (e.g., frontal lobe lesion).
- Other specified personality disorder and unspecified personality disorder is a category provided for two situations: 1) the individual's personality pattern meets the general criteria for a personality disorder, and traits of several different personality disorders are present, but the criteria for any specific personality disorder are not met; or 2) the individual's personality pattern meets the general criteria for a personality disorder, but the individual is considered to have a personality disorder that is not included in the DSM-5 classification (e.g., passive-aggressive personality disorder) General Personality Disorder A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
- Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
- Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
- Interpersonal functioning.
- Impulse control. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The pattern is stable and of long duration, and Its onset can be traced back at least to adolescence or early adulthood. E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. F. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).
- Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.
- Recognizable during adolescence or early adult life.
- For PD to be diagnosed in an individual younger than 18 years old, it has to be present for at least 1 year. - When an individual has a persistent mental disorder that was preceded by a preexisting PD, the PD must also be recorded, followed by “premorbid”. - When personality changes after exposure to extreme stress, PTSD should be considered. Cluster A Personality Disorder Paranoid Personality Disorder A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. 2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. 3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. 4. Reads hidden demeaning or threatening meanings into benign remarks or events. 5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights). 6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. 7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition. Note : If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “paranoid personality disorder (premorbid).” - Excessively mistrustful and suspicious of others, without justification. - Problems with close relationships. - Overt argumentativeness, in recurrent complaining, or by hostile aloofness - Need to have a high degree of control over those around them - Rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves. - More common among relatives who have schizophrenia. - Maybe due to early mistreatment or traumatic childhood experiences. - Associated with prior history of childhood mistreatment, externalizing symptoms, bullying, and adult appearance of interpersonal aggression. - “ I cannot trust people ” - Too much use of projection. - Males = Females - May experience brief psychotic episodes. - May develop MDD, Agoraphobia, and OCD - Most common co-occurring PD appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline. Schizoid Personality Disorder A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following: 1. Neither desires nor enjoys close relationships, including being part of a family. 2. Almost always chooses solitary activities. 3. Has little, if any, interest in having sexual experiences with another person. 4. Takes pleasure in few, if any, activities. 5. Lacks close friends or confidants other than first-degree relatives. 6. Appears indifferent to the praise or criticism of others. 7. Shows emotional coldness, detachment, or flattened affectivity. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition. Note : If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., “schizoid personality disorder (premorbid). - Detachment from social relationships and limited range of emotions. - Difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. - Tendency to turn inward and away from the outside world. - Childhood shyness is reported as a precursor to later personality disorder. - “ Relationships are messy and undesirable ” - Males > Females - Sometimes, experience brief psychotic episodes. Schizotypal Personality Disorder A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 1. Ideas of reference (excluding delusions of reference). 2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”: in children and adolescents, bizarre fantasies or preoccupations). 3. Unusual perceptual experiences, including bodily illusions. 4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped). 5. Suspiciousness or paranoid ideation. 6. Inappropriate or constricted affect. 7. Behavior or appearance that is odd, eccentric, or peculiar. 8. Lack of close friends or confidants other than first-degree relatives.
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- Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder. Note : If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”
- Typically socially isolated and behave in ways that would seem unusual to many of us, and they tend to be suspicious and to have odd beliefs.
- Ideas of reference : false beliefs that random or irrelevant occurrences in the world directly relate to oneself.
- Have odd beliefs or engage in magical thinking.
- Associated with childhood mistreatment and could be resulted from PTSD symptoms.
- “It is better to be isolated from others”
- Males > Females
- Often seek treatment for the associated symptoms of anxiety or depression rather than PD. Cluster B Personality Disorders Antisocial Personality Disorder A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
- Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
- Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
- Impulsivity or failure to plan ahead.
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
- Reckless disregard for safety of self or others.
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
- Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 15 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.
- Characterized as having history of failing to comply with social norms.
- At least 18 years of age.
- Evidence of CD before 15 years old.
- Irresponsible, impulsive, and deceitful.
- Lacking in conscience and empathy, selfishly take what they want and do as they please, violating social norms and expectations.
- CD will be given if the criteria for Antisocial PD is not met.
- Underarousal Hypothesis : psychopaths have abnormally low levels of cortical arousal.
- Fearlessness Hypothesis : psychopaths possess a higher threshold for experiencing fear than most other individuals.
- “ I am entitled to break rules ”
- Males > Females
- May experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood. Borderline Personality Disorder A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Frantic efforts to avoid real or imagined abandonment. ( Note : Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
- A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
- Identity disturbance : markedly and persistently unstable self-image or sense of self.
- Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.)
- Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
- Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
- Chronic feelings of emptiness.
- Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
- Transient, stress-related paranoid ideation or severe dissociative symptoms.
- Moods and relationships are unstable, and usually they have poor self-image.
- Have pattern of undermining themselves at the moment the goal is about to be realized.
- May feel more secure with transitional object than interpersonal relationships.
- Often feel empty and are great risk of dying by their own hands.
- Often engage to suicidal behaviors.
- Tend to have turbulent relationships, fearing abandonment but lacking control over their emotions.
- Often intense, going from anger to deep depression in a short time.
- Prevalent in families with history of mood disorders.
- If co-occurs with mood disorders, both are diagnosed.
- Recovery is more difficult and less stable.
- “ sad gorl iz me ”
- Females = Males
- Common co-occurring disorders including depressive and bipolar disorders, substance use disorders, anxiety. Histrionic Personality Disorder A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Is uncomfortable in situations in which he or she is not the center of attention.
- Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
- Displays rapidly shifting and shallow expression of emotions.
- Consistently uses physical appearance to draw attention to self.
- Has a style of speech that is excessively impressionistic and lacking in detail.
- Shows self-dramatization, theatricality, and exaggerated expression of emotion.
- Is suggestible (i.e., easily influenced by others or circumstances).
- Considers relationships to be more intimate than they actually are.
- Tend to be overly dramatic and almost to be acting.
- Express emotions in an exaggerated manner.
- Characterized by social dominance.
- More likely to get divorced or never get married.
- Have tendency to get bored with their usual routine.
- Histrionic and antisocial co-occur more often.
- “ ako ang bida ”
- Females > Males Narcissistic Personality Disorder A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicatedby five (or more) of the following:
- Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
- Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
- Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
- Requires excessive admiration.
- Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
- Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
- Lacks empathy : is unwilling to recognize or identify with the feelings and needs of others.
- Is often envious of others or believes that others are envious of him or her.
- Shows arrogant, haughty behaviors or attitudes.
- They consider themselves different from others and deserve special treatment.
- Unreasonable sense of self-importance and are so preoccupied with themselves that they lack sensitivity and compassion.
- Grandiosity
- Very sensitive to criticism.
- Interpersonal relations are typically impaired because of problems related to self-preoccupation, entitlement, need for admiration, and relative disregard for sensitivities of others.
- “ I am the greatest in the world ”
- Males > Females Cluster C Personality Disorders Avoidant Personality Disorder A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
- Is unwilling to get involved with people unless certain of being liked.
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. '
- Is preoccupied with being criticized or rejected in social situations.
- Is inhibited in new interpersonal situations because of feelings of inadequacy.
- Views self as socially inept, personally unappealing, or inferior to others.
- Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
- Extremely sensitive of the opinion of others and although they desire social relationship, their anxiety leads them to avoid.
- They are likely to misinterpret social responses as critical, which in turn confirms their self-doubts.
- Low self-esteem and hypersensitivity to rejection.
- Have insecure attachment style characterized by desire for emotional attachment.
- Extremely low self-esteem cause them to be limited with friendships and dependent to those they feel .comfy with
- Feel chronically rejected by others and pessimistic about their future.
- Negative self-concept.
- Social Anxiety Disorder– negative evaluations
- “ If they knew the real me, they would reject me ”
- Females > Males Dependent Personality Disorder A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
- Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
- Needs others to assume responsibility for most major areas of his or her life.
- Has difficulty expressing disagreement with others because of fear of loss of support or approval. ( Note : Do not include realistic fears of retribution.)
- Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
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appetite nearly every day. ( Note : In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or anothermedical condition. Note : Criteria A-C constitute a major depressive episode. Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note : Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. Bipolar I Disorder A. Criteria have been met for at least one manic episode (Criteria A-D under “Manic Episode” above). B. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. In recording the name of a diagnosis, terms should be listed in the following order: bipolar I disorder, type of current or most recent episode, severity/psychotic/remission specifiers, followed by as many specifiers without codes as apply to the current or most recent episode. Specify : With anxious distress With mixed features With rapid cycling With meianchoiic features With atypicai features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern o Grief is characterized by feelings of emptiness and loss. o MDE involves persistent depressed mood and an inability to anticipate happiness or pleasure. o Grief-related dysphoria tends to decrease in intensity over days to weeks, occurring in waves associated with thoughts or reminders of the deceased (pangs of grief). MDE's depressed mood is more persistent and not tied to specific thoughts or preoccupations. o The pain of grief may coexist with positive emotions and humor, contrasting with the pervasive unhappiness and misery of MDE. o Grief involves preoccupation with thoughts and memories of the deceased. MDE is characterized by self-critical or pessimistic ruminations. o In grief, self-esteem is generally preserved. MDE often involves feelings of worthlessness and self-loathing. o If present in grief, self-derogatory ideation is typically related to perceived failings in relation to the deceased. In MDE, thoughts about death and dying are focused on ending one's own life due to feelings of worthlessness, undeserving of life, or inability to cope with depression.
- At least 1 manic episode (elation and euphoria)
- Children should be judged according to his or her own baseline in determining whether a particular behavior is normal or evidence of manic episode.
- First episode usually MDE.
- Factors that should be considered: family history, onset, medical history, presence of psychotic symptoms, history of lack of response toantidepressant treatment or the emergence of manic episode during antidepressant treatment.
- The diagnosis is “ Bipolar I disorder, with psychotic features ” if the psychotic symptoms have occurred EXCLUSIVELY during manic and major depressive episodes.
- Symptoms of mania in BP1 occur in distinct episodes and typically begin in late adolescence or early adulthood.
- When any child is being assessed for Mania, it is essential that the symptoms represent clear change from the child’s typical behavior.
- Symptoms of mood lability and impulsivity must represent a distinct episode of illness, or there must be a noticeable increase in these symptoms over the individual’s baseline in order to justify an additional diagnosis of BP1.
- Young people who meet DSM-5 diagnostic criteria for BP display significant impairment in functioning, including previous hospitalization, MDD, treatment with medications, and co-occurring disruptive behavior and anxiety disorder.
- Youths may show irritability and rage or silly, giddy, overexcited, overly talkative behavior.
- Generally shorter than MDE, lasting from 4-6 .months if left untreated.
- Most frequently comorbid disorders are anxiety disorders, alcohol use disorder, other substance disorders, and ADHD. High rates of serious co-occurring and often untreated medical conditions. Bipolar II Disorder , requiring the lifetime experience of at least one episode of major depression and at least one hypomanie episode, is no longer thought to be a "milder" condition than bipolar I disorder. For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanic episode and the following criteria for a current or past major depressive episode: Hypomanic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. B. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior, and have been present to a significant degree:
- Inflated self-esteem or grandiosity.
- Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
- More talkative than usual or pressure to keep talking.
- Flight of ideas or subjective experience that thoughts are racing.
- Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or obsen/ed.
- Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.
- Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic. D. The disturbance in mood and the change in functioning are observable by others. E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment). Note : A full hypomanic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanie episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanie episode, nor necessarily indicative of a bipolar diathesis. Major Depressive Episode 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 not include symptoms that are clearly attributable to a medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- 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).
- 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 gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, a suicide attempt, or a specific plan for committing suicide. B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or another medical condition. Note : Criteria A-C above constitute a major depressive episode. Note : Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a
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significant loss should be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. Bipolar II Episode A. Criteria have been met for at least one hypomanic episode (Criteria A-F under “Hypomanic Episode” above) and at least one major depressive episode (Criteria A-C under “Major Depressive Episode” above). B. There has never been a manic episode. C. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. D. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify current or most recent episode : Hypomanie Depressed Specify if : With anxious distress With mixed features With rapid cycling Withi mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With peripartum onset With seasonal pattern : Applies only to the pattern of major depressive episodes. Specify course if full criteria for a mood episode are not currently met : In partial remission In full remission Specify severity if full criteria for a mood episode are currently met : Mild Moderate Severe
- MDE + Hypomanic episodes
- Often begins with depressive episodes.
- Highly recurrent
- Once hypomanic episode has occurred, it never reverts back to MDD.
- BP2 is distinguished from cyclothymic disorder by the presence of one or more hypomanic episodes and one or more MDE.
- Common feature is impulsivity
- Heightened levels of creativity during hypomanic episodes.
- Perform more poorly than healthy individuals on cognitive tests, may contribute to vocational difficulties.
- More often than not associated with one or more co-occurring mental disorders, with anxiety disorders being the most common.
- Risk tends to be highest among relatives of individuals with BPII, as opposed to individuals with BP1 or MDD. Cyclothymic Disorder A. For at least 2 years (at least 1 year in children and adolescents) there have been numerous periods with hypomanic symptoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. B. During the above 2-year period (1 year in children and adolescents), the hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time. C. Criteria for a major depressive, manic, or hypomanic episode have never been met. D. The symptoms in Criterion A are not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. E. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if : With anxious distress
- Milder but more chronic version of bipolar disorder.
- Do not meet the complete criteria for depressive symptoms and hypomanic symptoms.
- MDD, BP1, and BP2 are more common among first degree biological relatives of indivs with cyclothymic disorder.
- Substance-related disorders and sleep disorders may be present in individuals with cyclothymic disorder. Substance/Medication-Induced Bipolar and Related Disorder A. A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by elevated, expansive, or irritable mood, with or without depressed mood, or markedly diminished interest or pleasure in all, or almost all, activities. B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2):
- The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
- The involved substance/medication is capable of producing the symptoms in Criterion A. C. The disturbance is not better explained by a bipolar or related disorder that is not substance/medication-induced. Such evidence of an independent bipolar or related disorder could include the following: The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non- substance/medication-induced bipolar and related disorder (e.g., a history of recurrent non-substance/medication-related episodes). D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for diagnoses associated with substance class): With onset during intoxication : If the criteria are met for intoxication with the substance and the symptoms develop during intoxication. With onset during withdrawal : If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
- An exception is made for hypomania or mania resulting from antidepressant medication use or other treatments that persist beyond the physiological effects of the medication. Such cases are indicative of true bipolar disorder, not substance/medication-induced bipolar and related disorder.
- Individuals experiencing apparent electroconvulsive therapy-induced manic or hypomanic episodes that persist beyond the treatment's physiological effects are diagnosed with bipolar disorder, not substance/medication-induced bipolar and related disorder. Bipolar and Related Disorder Due to Another Medical Condition A. A prominent and persistent period of abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy that predominates in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. C. The disturbance is not better explained by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning, or necessitates hospitalization to prevent harm to self or others, or there are psychotic features. Specify if : With manic features : Full criteria are not met for a manic or hypomanic episode. With manic- or hypomanic-like episode : Full criteria are met except Criterion D for a manic episode or except Criterion F for a hypomanic episode. With mixed features : Symptoms of depression are also present but do not predominate in the clinical picture.
- Manic or hypomanic episodes in bipolar and related disorder due to another medical condition usually appear during the initial presentation of the medical condition (within 1 month).
- Exceptions may occur in chronic medical conditions that worsen or relapse, leading to the manifestation of manic or hypomanic symptoms.
- Proper diagnosis excludes bipolar and related disorder due to another medical condition when manic or hypomanic episodes definitely precede the onset of the medical condition.
- An exception to the above is when all preceding manic or hypomanic episodes were associated with the ingestion of a substance/medication. Other Specified Bipolar Disorder and Related Disorder This category applies to presentations in which symptoms characteristic of a bipolar and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the bipolar and related disorders diagnostic class. The other specified bipolar and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific bipolar and related disorder. This is done by recording “other specified bipolar and related disorder” followed by the specific reason (e.g., “short-duration cyclothymia”). Examples of presentations that can be specified using the “other specified” designation include the following:
- Short-duration hypomanic episodes (2-3 days) and major depressive episodes : A lifetime history of one or more major depressive episodes in individuals whose presentation has never met full criteria for a manic or hypomanic episode but who have experienced two or more episodes of short- duration hypomania that meet the full symptomatic criteria for a hypomanic episode but that only last for 2-3 days. The episodes of hypomanic symptoms do not overlap in time with the major depressive episodes, so the disturbance does not meet criteria for major depressive episode, with mixed features.
- Hypomanic episodes with insufficient symptoms and major depressive episodes : A lifetime history of one or more major depressive episodes in
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become euthymie (not sad) even for extended periods of time if the external circumstances remain favorable. Increased appetite may be manifested by an obvious increase in food intake or by weight gain. Hypersomnia may include either an extended period of nighttime sleep or daytime napping that totals at least 10 hours of sleep per day (or at least 2 hours more than when not depressed). Leaden paralysis is defined as feeling heavy, leaden, or weighted down, usually in the arms or legs. This sensation is generally present for at least an hour a day but often lasts for many hours at a time. Unlike the other atypical features, pathological sensitivity to perceived interpersonal rejection is a trait that has an early onset and persists throughout most of adult life. Rejection sensitivity occurs both when the person is and is not depressed, though it may be exacerbated during depressive periods. With psychotic features : Delusions or hallucinations are present at any time in the episode. If psychotic features are present, specify if mood-congruent or mood- incongruent: With mood-congruent psychotic features : During manic episodes, the content of all delusions and hallucinations is consistent with the typical manic themes of grandiosity, invulnerability, etc., but may also include themes of suspiciousness or paranoia, especially with respect to others’ doubts about the individual’s capacities, accomplishments, and so forth. With mood-incongruent psychotic features : The content of delusions and hallucinations is inconsistent with the episode polarity themes as described above, or the content is a mixture of mood-incongruent and mood-congruent themes. With catatonia : This specifier can apply to an episode of mania or depression if catatonic features are present during most of the episode. With peripartum onset : This specifier can be applied to the current or, if the full criteria are not currently met for a mood episode, most recent episode of mania, hypomania, or major depression in bipolar I or bipolar II disorder if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Note : Mood episodes can have their onset either during pregnancy or postpartum. Although the estimates differ according to the period of follow-up after delivery, between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or in the weeks or months following delivery. Fifty percent of “postpartum” major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as peripartum episodes. Women with peripartum major depressive episodes often have severe anxiety and even panic attacks. Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode. Peripartum-onset mood episodes can present either with or without psychotic features. Infanticide is most often associated with postpartum psychotic episodes that are characterized by command hallucinations to kill the infant or delusions that the infant is possessed, but psychotic symptoms can also occur in severe postpartum mood episodes without such specific delusions or hallucinations. With seasonal pattern : This specifier applies to the lifetime pattern of mood episodes. The essential feature is a regular seasonal pattern of at least one type of episode (i.e., mania, hypomania, or depression). The other types of episodes may not follow this pattern. For example, an individual may have seasonal manias, but his or her depressions do not regularly occur at a specific time of year. A. There has been a regular temporal relationship between the onset of manic, hypomanic, or major depressive episodes and a particular time of the year (e.g., in the fall or winter) in bipolar I or bipolar II disorder. Note : Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter). B. Full remissions (or a change from major depression to mania or hypomania or vice versa) also occur at a characteristic time of the year (e.g., depression disappears in the spring). C. In the last 2 years, the individual’s manic, hypomanie, or major depressive episodes have demonstrated a temporal seasonal relationship, as defined above, and no non-seasonal episodes of that polarity have occurred during that 2 - year period. D. Seasonal manias, hypomanias, or depressions (as described above) substantially outnumber any nonseasonal manias, hypomanias, or depressions that may have occurred over the individual’s lifetime. Note : This specifier can be applied to the pattern of major depressive episodes in bipolar I disorder, bipolar II disorder, or major depressive disorder, recurrent. The essential feature is the onset and remission of major depressive episodes at characteristic times of the year. Specify if : In partial remission : Symptoms of the immediately previous manic, hypomanic, or depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanie, or major depressive episode following the end of such an episode. In full remission : During the past 2 months, no significant signs or symptoms of the disturbance were present. Specify current severity : Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability. Mild : Few, if any, symptoms in excess of those required to meet the diagnostic criteria are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning. Moderate : The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.” Severe : The number of symptoms is substantially in excess of those required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning. Depressive Disorders The common feature of all of these disorders is the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual's capacity to function. Disuptive Mood Dysregulation Disorder A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times per week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). E. Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A-D. F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) and are severe in at least one of these. G. The diagnosis should not be made for the first time before age 6 years or after age 18 years. H. By history or observation, the age at onset of Criteria A-E is before 10 years. I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note : Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). Note : This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.
- Recurrent temper outburst (verbally or behaviorally) that are grossly out of proportion.
- 3 or more times/week
- Irritable or angry most of the day
- 12 or more months, at least 2 settings
- Onset should be after 6 yrs-18yrs.
- Factors associated with disrupted family life.
- Family history of depression may be a risk factor
- Do not occur exclusively during MDE.
- Bipolar = episodic, DMDD = persistent
- Diagnosis cannot be assigned to a child who has ever experienced full-duration hypomanic or manic episode (irritable or euphoric) or who has ever had a manic or hypomanic episode lasting more than 1 day.
- Presence of severe and frequently recurrent outburst and persistent disruption in mood between outburst.
- Severe in at least one setting and mild to moderate to second setting.
- Children with DMDD should not have symptoms that meet criteria for BD, as in that context, only the bipolar disorder diagnosis should be made.
- If children have symptoms that meet criteria for ODD or IED and DMDD, then only DMDD is the diagnosis. Major Depressive Disorder 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 not include symptoms that are clearly attributable to another medical condition.
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). ( Note : In children and adolescents, can be irritable mood.)
- 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).
- 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 gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
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B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The episode is not attributable to the physiological effects of a substance or to another medical condition. Note : Criteria A-C represent a major depressive episode. Note : Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode. Note : This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition. In recording the name of a diagnosis, terms should be listed in the following order: major depressive disorder, single or recurrent episode, severity/psychotic/remission specifiers,followed by as many of the following specifiers without codes that apply to the current episode. Specify : With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With catatonia With péripartum onset With seasonal pattern (recurrent episode only)
- Grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inability to anticipate happiness or pleasure.
- At least 2 weeks of either anhedonia or depressed mood.
- Associated with high mortality.
- Hyperactivity in HPA axis and it appears to be associated with melancholia, psychotic features, and risks for eventual suicide.
- “Other specified depressive disorder” can be made in addition to the diagnosis of psychotic disorder, if the depressive symptoms meet full criteria for MDE.
- In schizoaffective, delusions or hallucinations occur exclusively for 2 weeks without MDE.
- Seasonal, Catatonic, Melancholic
- Other disorders with which MDD co-occurs are substance-related disorders, panic disorder, GAD, PTSD, OCD, AN, BN, and Borderline PD. Persistent Depressive Disorder (Dysthymia) This disorder represents a consolidation of DSM-lV-defined chronic major depressive disorder and dysthymic disorder. A. Depressed mood for most of the day, for more days than not, as indicated by either 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:
- Poor appetite or overeating.
- Insomnia or hypersomnia.
- Low energy or fatigue.
- Low self-esteem.
- Poor concentration or difficulty making decisions.
- Feelings of hopelessness. C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria A and B for more than 2 months at a time. D. Criteria for a major depressive disorder may be continuously present for 2 years. E. There has never been a manic episode or a hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism). H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Note: Because the criteria for a major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet criteria for persistent depressive disorder. If full criteria for a major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise, a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted. Specify if : With anxious distress With mixed features With melancholic features With atypical features With mood-congruent psychotic features With mood-incongruent psychotic features With péripartum onset Specify if : In partial remission In full remission Specify if : Early onset : If onset is before age 21 years. Late onset : If onset is at age 21 years or older. Specify if (for most recent 2 years of persistent depressive disorder): With pure dysthymic syndrome : Full criteria for a major depressive episode have not been met in at least the preceding 2 years. With persistent major depressive episode : Full criteria for a major depressive episode have been met throughout the preceding 2-year period. With intermittent major depressive episodes, with current episode : Full criteria for a major depressive episode are currently met, but there have been periods of at least 8 weeks in at least the preceding 2 years with symptoms below the threshold for a full major depressive episode. With intermittent major depressive episodes, without current episode : Full criteria for a major depressive episode are not currently met, but there has been one or more major depressive episodes in at least the preceding 2 years. Specify current severity: Mild Moderate Severe
- Depressed mood for at least 2 years.
- If full criteria for a MDE has been met at some point during the period of illness, a diagnosis of MDD would apply. Otherwise, a diagnosis of “other specified depressive disorder” or “unspecified depressive disorder” should be given.
- A separate diagnosis of PDD is not made if the symptom occur only during the course of the psychotic disorder.
- Double Depression : suffer from both MDE and PDD with fewer symptoms. Premenstrual Dysphoric Disorder A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses. B. One (or more) of the following symptoms must be present:
- Marked affective lability (e.g., mood swings: feeling suddenly sad or tearful, or increased sensitivity to rejection).
- Marked irritability or anger or increased interpersonal conflicts.
- Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
- Marked anxiety, tension, and/or feelings of being keyed up or on edge. C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.
- Decreased interest in usual activities (e.g., work, school, friends, hobbies).
- Subjective difficulty in concentration.
- Lethargy, easy fatigability, or marked lack of energy.
- Marked change in appetite; overeating; or specific food cravings.
- Hypersomnia or insomnia.
- A sense of being overwhelmed or out of control.
- Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain. Note : The symptoms in Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year. D. The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home). E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co- occur with any of these disorders). F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. ( Note : The diagnosis may be made provisionally prior to this confirmation.) G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).
- Majority of menstrual cycles, at least 5 symptoms must be present.
- Delusions and hallucinations have been described in the late luteal phase of the menstrual cycle but are rare.
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C. Criteria are not met for “with melancholic features” or “with catatonia” during the same episode. With psychotic features : Delusions and/or hallucinations are present. With mood-congruent psychotic features : The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. With mood-incongruent psychotic features : The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes. With catatonia : The catatonia specifier can apply to an episode of depression if catatonic features are present during most of the episode. With peripartum onset : This specifier can be applied to the current or, if full criteria are not currently met for a major depressive episode, most recent episode of major depression if onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. With seasonal pattern : This specifier applies to recurrent major depressive disorder. A. There has been a regular temporal relationship between the onset of major depressive episodes in major depressive disorder and a particular time of the year (e.g., in the fall or winter). Note : Do not include cases in which there is an obvious effect of seasonally related psychosocial stressors (e.g., regularly being unemployed every winter). B. Full remissions (or a change from major depression to mania or hypomania) also occur at a characteristic time of the year (e.g., depression disappears in the spring). C. In the last 2 years, two major depressive episodes have occurred that demonstrate the temporal seasonal relationships defined above and no nonseasonal major depressive episodes have occurred during that same period. D. Seasonal major depressive episodes (as described above) substantially outnumber the nonseasonal major depressive episodes that may have occurred over the individual’s lifetime. Specify if : In partial remission : Symptoms of the immediately previous major depressive episode are present, but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a major depressive episode following the end of such an episode. In full remission : During the past 2 months, no significant signs or symptoms of the disturbance were present. Specify current severity : Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability. Mild : Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning. Moderate : The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.” Severe : The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning. Anxiety Disorders Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. With fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors. Separation Anxiety Disorder A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:
- Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.
- Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.
- Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.
- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.
- Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.
- Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.
- Repeated nightmares involving the theme of separation.
- Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.
- Concerns with real or imagined separating from attachment figures.
- Separation may lead to extreme anxiety and panic attacks.
- Not entirely responsible for school absences or school avoidance.
- Do not attend school so they won’t be separated with their attachment figure.
- Fear of possible separation is the central thought.
- Concerned about the proximity and safety of key attachment figures.
- Develops after life stress, bullying and a history of parental overprotection and intrusiveness.
- Heritable
- Highly co-morbid with GAD and Specific Phobia in children
- For Adults, common comorbidities inc. phobia, PTSD, Panic Disorder, GAD, SAD, Agora, OCD, Prolonged Grief Disorder, PD (Dependent, Avoidant, and OCPD), MDE and Bipolar Disorders At least 4 weeks (children) or 6 months or more (adults) Selective Mutism A. Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. B. The disturbance interferes with educational or occupational achievement or with social communication. C. The duration of the disturbance is at least 1 month (not limited to the first month of school). D. The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. E. The disturbance is not better explained by a communication disorder (e.g., childhoodonset fluency disorder) and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.
- Rare childhood disorder
- Characterized by a lack of speech in one or more setting in which speaking is socially expected.
- Restricted to a specific social situation.
- A child could speak in one setting but cannot/do not in another setting.
- Not better explained by communication disorder
- Only diagnosed when a child has established a capacity to speak in some social situations.
- Learn to perform avoidance and safety behaviors to avoid disasters
- Children with selective mutism are almost always given an additional diagnosis of another anxiety disorder (usually, Social Anxiety).
- Increased abnormalities in the auditory efferent neural activity during vocalization.
- Parents are described to be overprotective or more controlling.
- At least 1 month. Specific Phobia A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). Note : In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. B. The phobic object or situation almost always provokes immediate fear or anxiety. C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. F. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. G. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia): objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder). Specify if : Code based on the phobic stimulus:
- Animal (e.g., spiders, insects, dogs).
- Natural environment (e.g., heights, storms, water).
- Blood-injection-injury (e.g., needles, invasive medical procedures). Coding note : Select specific ICD- 10 - CM code as follows: fear of blood; fear of injections and transfusions; fear of other medical care; or fear of injury; situational (e.g., airplanes, elevators, enclosed places).
- Other (e.g., situations that may lead to choking or vomiting: in children, e.g., loud sounds or costumed characters). Coding note : When more than one phobic stimulus is present, code all ICD- 10 - CM code that apply (e.g., for fear of snakes and flying, specific phobia, animal, and specific phobia, situational).
- Irrational fear of a specific object or situation that markedly interferes with an individual’s ability to function.
- Acquired through direct experience, experiencing in false alarm, and observation
- It only fears one setting, unlike Agoraphobia (which requires 3 settings), then Specific Phobia-Situational can be diagnosed.
- Usually develops during childhood.
- There may be genetic susceptibility to certain category of specific phobia.
- Animal, Natural Environment, and Situational-Specific Phobias ~ Women > Men
- Blood-Injection-Injury Phobia ~ Women = Men
- Increased risk for the development of other disorder such as other anxiety disorders, depressive and bipolar disorders, substance related disorders, somatic disorders, and PD.
- 6 months or more Social Anxiety Disorder A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being
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observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note : In children, the anxiety must occur in peer settings and not just during interactions with adults. B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others). C. The social situations almost always provoke fear or anxiety. Note : In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. D. The social situations are avoided or endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmoφhic disorder, or autism spectrum disorder. J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. Specify if : Performance only : If the fear is restricted to speaking or performing in public
- Fear or anxiety about possible embarrassment or scrutiny.
- Can have panic attacks but it is cued by social situations.
- Typically have adequate age-appropriate social relationships and social communication capacity.
- Self-medication with substances is common
- Blushing : hallmark physical response of Social Anxiety Disorder
- Heritable
- Paruresis : difficulty peeing in public restrooms or with people nearby
- Chronic Isolation in the course of Social Anxiety Disorder may result to MDD
- Frequently co-morbid with BDD and Avoidant PD
- In children, comorbidities with high-functioning ASD and Selective Mutism are common.
- 6 months or more Panic Disorder A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur; Note : The abrupt surge can occur from a calm state or an anxious state.
- Palpitations, pounding heart, or accelerated heart rate.
- Sweating.
- Trembling or shaking.
- Sensations of shortness of breath or smothering.
- Feelings of choking.
- Chest pain or discomfort.
- Nausea or abdominal distress.
- Feeling dizzy, unsteady, light-headed, or faint.
- Chills or heat sensations.
- Paresthesias (numbness or tingling sensations).
- Derealization (feelings of unreality) or depersonalization (being detached from oneself).
- Fear of losing control or “going crazy.”
- Fear of dying. Note : Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
- Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
- A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders). D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder: in response to circumscribed phobic objects or situations, as in specific phobia: in response to obsessions, as in obsessive- compulsive disorder: in response to reminders of traumatic events, as in posttraumatic stress disorder: or in response to separation from attachment figures, as in separation anxiety disorder).
- Cannot be diagnosed unless full symptom panic attacks were experienced.
- Norepinephrine activities are irregular
- Abrupt surge of intense fear or discomfort out of nowhere, with no triggers.
- Followed by persistent concerns about more attacks or the consequences of it or maladaptive change in behavior related to the attacks.
- Women > men Panic Attack Specifier Note : Symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g., depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Note : The abrupt surge can occur from a calm state or an anxious state. 1. Palpitations, pounding heart, or accelerated heart rate. 2. Sweating. 3. Trembling or shaking. 4. Sensations of shortness of breath or smothering. 5. Feelings of choking. 6. Chest pain or discomfort. 7. Nausea or abdominal distress. 8. Feeling dizzy, unsteady, light-headed, or faint. 9. Chilis or heat sensations. 10. Paresthesias (numbness or tingling sensations). 11. Derealization (feelings of unreality) or depersonalization (being detached from oneself). 12. Fear of losing control or “going crazy.” 13. Fear of dying. Note : Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms. Agoraphobia A. Marked fear or anxiety about two (or more) of the following five situations: 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes). 2. Being in open spaces (e.g., parking lots, marketplaces, bridges). 3. Being in enclosed places (e.g., shops, theaters, cinemas). 4. Standing in line or being in a crowd. 5. Being outside of the home alone. B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic- like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence). C. The agoraphobic situations almost always provoke fear or anxiety. D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive. I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder): and are not rellated exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmoφhic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder). Note : Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.
- Developed after a person has unexpected panic attacks.
- Fear in two or more situations (public transpo, open spaces, enclosed spaces, standing in line, being outside of the home alone) due to thoughts that escape might be difficult or no one will help them in case panic-like symptoms would manifest.
- Has the strongest and most specific association with the genetic factor that represent proneness to phobia.
- 90% of individuals with agoraphobia also have other mental disorders.
- 6 months or more. Generalized Anxiety Disorder 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 individual 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 having been present for more days than not for the past 6 months); Note : Only one item is required in children.
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Irritability.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep). D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). F. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body
