DSM5

Autism Spectrum Disorder

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by all of the following: deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors used for social interaction, and deficits in developing, maintaining, and understanding relationships

Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following: stereotyped or repetitive motor movements, use of objects, or speech; insistence on sameness, inflexible adherence to routine, or ritualized patterns of verbal or nonverbal behavior; highly restricted, fixated interests that are abnormal in intensity or focus; hyper or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

Symptoms must be present in the early development period (but may not become fully manifest until social demands exceed limited capacities)

Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning

These disturbances are not better explained by intellectual development disorder or global developmental delay

Autism Spectrum Disorder Specifications

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior: requiring very substantial support, requiring substantial support, requiring support

Specify if: with or without accompanying intellectual impairment, with or without accompanying language impairment

Specify if: associated with a known genetic or other medical condition or environmental factor

Specify if: with catatonia

Autism severity level 3: Requiring Very Substantial Support

Social communication: Severe deficits in verbal and nonverbal social communication skills that cause severe impairments in functioning, limited social interactions, and minimal response to social overtures from others

Restricted, repetitive behavior: Inflexibility of behavior, extreme difficulty coping with change, or other restricted/repetitive behaviors markedly interfere with functioning in all spheres. Great distress/difficulty changing focus or action

Autism Spectrum Disorder Level 2: Requiring Substantial Support

Social Communication: Marked deficits in verbal and nonverbal social communication skills; social impairment apparent even with supports in place, limited initiation of social interactions and reduced or abnormal responses to social overtures from others

Restricted, repetitive behaviors: Inflexibility of behavior, difficulty coping with change, or other restricted/repetitive behaviors appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress and/or difficulty changing focus or action

Autism Spectrum Disorder Level 1: Requiring Support

Social Communication: Without supports in place, deficits in social communication cause noticeable impairments. Difficulty initiating social interactions, and clear examples of atypical or unsuccessful responses to social overtures of others. May appear to have decreased interest in social interactions.

Restricted, repetitive behaviors: Inflexibility of behavior causes significant interference with functioning in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence

Autism Prevalence

In the U.S. between 1-2% of the population. Lower among American Americans and Latinx children. Male:female ratio is 3:1

Autism Development and Course

Symptoms are typically recognized between 12-24 months but may be seen earlier if symptoms are more subtle. Most cases the onset is associated with declines in critical social and communication behaviors in the first 2 years of life. First symptoms frequently involve delayed language development, often accompanied by lack of social interest or unusual social interactions

Autism Hereditary Estimates

Range from 37% to higher than 90%, based on twin concordance rates, and a more recent five-country cohort estimated heritability at 80%

Other Risks of Autism

Individuals with autism are at greater risk of suicide death compared to with those without.

Lack of social and communication abilities may hamper learning.

In the home, insistence on routines and aversion to change, as well as sensory sensitivities, may interfere with eating and sleeping and make routine care extremely difficult

Attention-Deficit/Hyperactivity Disorder

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) inattention and/or (2) hyperactivity and impulsivity

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 negatives impacts directly on social and academic/occupational activities: often fails to give close attention to details or makes careless mistakes in schoolwork or at work, often has difficulty sustaining attention in tasks or play activities, often does not seem to listen when spoken to directly, often does not follow through on instructions and fails to finish work, often has difficulty organizing tasks and activities, often avoids dislikes or is reluctant to engage in tasks that require sustained mental effort, Often loses things necessary for tasks or activities, Is often easily distracted by extraneous stimuli, is often forgetful in daily activities

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 other activities; often fidgets with pr taps hands or feet or squirms in seat, often leaves seat in situations when remaining seated is expected, often runs about or climbs in situations where it is inappropriate, often unable to play or engage in leisure activities quietly, is often “on the go”, often talks excessively, often blurts out an answer before a question has been completed, often interrupts or intrudes on others

Several inattentive or hyperactive-impulsive symptoms were present prior to age 12

Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (Ex: at home, school, or work)

There is clear evidence that the symptoms interfere with social, academic, or occupational functioning

The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder

ADHD Specifications

F90.2 Combined presentation: If both Criterion A1 and Criterion A2 are met for the past 6 months

F90.0 Predominantly inattentive presentation: If Criterion A1 is met but Criterion A2 is not met for the past 6 months

F90.1 Predominantly hyperactive/impulsive presentation: If Criterion A2 is met and Criterion A1 is not met for the past 6 months

Specify if: in partial remission

Specify if: mild, moderate, severe

Severe ADHD

Many symptoms in excess of those required to make the diagnosis, or several symptoms that are particularly severe, are present, or the symptoms result in marked impairment in social or occupational functioning

Moderate ADHD

Symptoms or functional impairment between “mild” and “severe” are present

Mild ADHD

Few, if any, symptoms in excess of those required to make the diagnosis are present, and symptoms result in no more than minor impairments in social or occupational functioning

ADHD Prevalence

Worldwide in about 7.2% of children, higher in special populations such as foster children or correctional settings. Occurs in about 2.5% of adults

ADHD Risk and Prognostic Factors

Temperamental: Associated with reduced behavioral inhibition, effortful control or constraint; negative emotionality and/or elevated novelty seeking

Environmental: Very low birth weight and degree of prematurity convey a greater risk. The more extreme the low weight, the higher the risk. Prenatal exposure to smoking is associated with it as well.

Genetic and physiological: Heritability is approximately 74%.

ADHD is more likely in males

True

Functional Consequences of ADHD

Associated with reduced school performance and academic attainment. Associated with poor job stability. Individuals with ADHD obtain less schooling, have poorer vocational achievement, and have reduced intellectual scores than their peers, although there is great variability

Specific Learning Disorder

Difficulties learning and using academic skills, as indicated by the presence of at least one of the following symptoms that have persisted for at least 6 months, despite the provision of interventions that target those difficulties: inaccurate or slow and effortful word reading, difficulty understanding the meaning of what is read, difficulties in spelling, difficulties with written expression, difficulties mastering number sense/calculation, and difficulties with mathematical reasoning

The affected academic skills are substantially and quantifiably below those expected for the individual’s chronological age and cause significant interference with academic or occupational performance

The learning difficulties begin during school-age years but may not become fully manifested until the demands for those affected academic skills exceed the individuals limited capacities (Ex: timed test)

The learning difficulties are not better accounted for by intellectual disabilities, uncorrected visual or auditory acuity, or other mental or neurological disorders and educational instruction

Specific Learning Disorder Specifications

F81.0 With Impairment in reading

F81.81 With Impairment in written expression

F81.2 With Impairment in Mathematics

Specific Learning Disorder: Mild

Some difficulties learning skills in one or two academic domains, but of mild enough severity that the individual may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years

Specific Learning Disorder: Moderate

Marked difficulties learning skills in one or more academic domains, so that the individual is unlikely to become proficient without some intervals of intensive and specialized teaching during the school years. Accommodations or support services sometimes needed to complete activities accurately and efficiently

Specific Learning Disorder: Severe

Severe difficulties learning skills, affecting several academic domains, so that the individual is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years. Even with intense help. the individual may not be able to complete all activities efficiently

Specific Learning Disorder Prevalence

Prevalence across academic domains of reading, writing, and mathematics is 5-15% among school-age children

Specific Learning Disorder Development and Course

Onset and recognition usually occur during the elementary school years. Manifestations may be behavioral and this disorder is lifelong. Male/female ratio is 2:1

Developmental Coordination Disorder

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 (dropping items) as well as slowness and inaccuracy of performance of motor skills (can’t catch)

The motor skills deficit in Criterion A significantly and persistently interferes with activities of daily living appropriate to chronological age (Ex: self-care and self-maintenance)

Onset of symptoms is in the early developmental period

The motor skills deficits are not better explained by intellectual developmental disorder or visual impairment and are not attributable to a neurological condition affecting movement

Developmental Coordination Disorder Prevalence

In children ages 5-11 years ranges from 5-8% across countries with males more often affected

Developmental Coordination Disorder Development and Course

Stable at least to 1 year and 2 year follow up. Although there may be improvements in the longer term, problems with coordinated movements continue through adolescence in an estimated 50-70% of children. Delayed motor milestones may be first sign

Stereotypic Movement Disorder

Repetitive, seemingly driven, and apparently purposeloss motor behavior

The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury

Onset is in the early developmental period

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

Stereotypic Movement Disorder Specifications

Specify if: With-self injuries behavior, without self-injurious behavior

Specify if: Associated with a known genetic or other medical condition, neurodevelopmental disorder, or environmental factor

Specify if: Mild, moderate, severe (mild: symptoms easily suppressed by sensory distraction. moderate: symptoms require explicit protective measures and behavioral modification. Severe: Continuous monitoring and protective measures are required to prevent serious injury

Stereotypic Movement Disorder Prevalence

Simple movements are common in young typically development children (5-19%). Complex movements are much less common (3-4%). Common in those with intellectual developmental disorders

Delusions

Fixed beliefs that are not amenable to change in light of conflicting evidence. Deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences. (Ex: Belief that an outside force has removed their organs and replaced them without leaving any scars)

Persecutory Delusions

Belief that one group is going to be harmed, harassed, and so forth by an individual, organization, or other group) are the most common delusions

Referential Delusions

Belief that certain gestures, comments, environmental cues, and so forth are directed at oneself

Grandiose Delusions

When an individual beliefs that he or she has exceptional abilities, wealth, or fame

Erotomanic Delusions

When an individual believes falsely that another person is in love with him or her

Nihilistic Delusions

Involve the conviction that a major catastrophe will occur

Somatic Delusions

Focus on preoccupations regarding health and organ function

Hallucinations

Perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. Auditory are most common. Those that occur while falling asleep (hypnagogic) or waking up (hypnopompic) are considered to be within the range of normal experience.

Disorganized Thinking (Speech)

Also called formal thought disorder. Inferred from the individual’s speech. May switch from one topic to another (derailment or loose associations). Answers to questions may be obliquely related or completely unrelated (tangentiality). The symptom must be severe enough to substantially impair effective communication

These two negative symptoms are particularly prominent in schizophrenia

Diminished emotional expression and avolition.

Diminished Emotional Expression

Includes reductions in the expression of emotions in the face, eye context, intonation of speech (prosody), and movements of the body that normally give an emotional emphasis to speech

Avolition

A decrease in motivated self-initiated purposeful activities. Individual may sit for long periods of time and show little interest in participating in work or social activities.

Delusion Disorder

A: The presence of one or more delusions with a duration of 1+ month

B: Criterion A for schizophrenia has never been met

C: Apart from the impact of the delusions 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 OCD

Specify If: Erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified

Specify if: With Bizarre Content

Specify: Amount of episodes/level of remission

Development and Course for Delusion Disorder

On average, global functioning is generally better than that observed in schizophrenia. May be more prevalent in older individuals

Risk and Prognostic Factors for Delusion Disorder

Genetic and physiological. Delusion disorder has a significant familial relationship with both schizophrenia and schizotypal personality disorder

Brief Psychotic Disorder

A: Presence of one or more of the following systems. At least one of these must be (1), (2), or (3):

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

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

Specify if: With marked stressors, without marked stressors, with peripartum onset

Specify if: Catatonia

Specify current severity

Development and Course for Brief Psychotic Disorder

May appear in adolescence or early adulthood, and onset can occur across the lifespan, with the average age at onset being the mid 30’s

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)

1. Delusions

2. Hallucinations

3. Disorganized Speech

4. Grossly Disorganized or Catatonic Behavior

5. Negative Symptoms

B: An episode of the disorder lasts at least 1 month but less than 6. 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, 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

Specify if: With/without Good Prognostic Features

Specify if: With Catatonia

Specify Current Severity

Difference between Schizophreniform and Schizophrenia

Schizophreniform disorder is distinguished by its difference in duration: the total duration of the illness, including prodromal, active, and residual phases, is at least 1 month but less than 6 months. The duration requirement for schizophreniform disorder is intermediate between that for brief psychotic disorder, with lasts more than 1 day and remits by 1 month, and schizophrenia, which lasts for at least 6 months.

Schizophrenia

A: Two or more of the following, each present for a significant portion of time during a 1 month period. At least one of these must be (1), (2), or (3)

1. Delusions

2. Hallucinations

3. Disorganized Speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

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)

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 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

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

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: amount of episodes/level of remission

Specify if: With Catatonia

Associated Features of Schizophrenia

Individuals may display inappropriate affect (laughing in the absence of an appropriate stimulus), a dysphoric mood that can take form of depression, anxiety, or anger or a disturbed sleep pattern. anxiety and phobias are common. Common cognitive deficits include decrements in declarative memory, working memory, language function, and other executive functions, as well as slower processing speed.

Development and Course of Schizophrenia

Typically emerge between the late teens and mid 30’s, onset prior to adolescence is rare. The peak onset age occurs in the early to mid 20’s for men and in the late 20s for women. Onset may be abrupt or insidious, but the majority of individuals manifest a slow and gradual development of a variety of clinically significant signs and symptoms

Schizophrenia and Suicide Thoughts and Behavior

Approximately 5-6% of individuals die by suicide, about 20% attempt suicide on one or more occasions.

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

B: Delusions or hallucinations for two 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 or another medical condition

Specify if: Bipolar or depressive type

Specify if: With catatonia

Specify if: Amount of episodes/level of remission

Difference between schizophrenia and schizoeffective

Schizophrenia is primarily characterized by psychotic symptoms such as hallucinations and delusions, while schizoaffective disorder includes these psychotic symptoms along with significant mood disorder symptoms like depression or mania.

Development and Course of Schizoaffective Disorder

Typical age of onset of schizoaffective disorder is early adulthood, although onset can occur anytime from adolescence to late in life.

Substance/Medication-Induced Psychotic Disorder

A: Presence of one or both of the following symptoms

1. Delusions

2. Hallucinations

B: There is evidence from the history, physical examination, or laboratory findings of both (1) and (2)

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication

2. The involved substance/medication is capable of producing the symptoms in Criterion A

C: The disturbance is not better explained by a psychotic disorder that is not substance/medication-induced.

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: With onset during intoxication/withdrawal/medication use

Psychotic Disorders can occur in association with intoxication with the following classes of substances

Alcohol; cannabis; hallucinogens, including phencyclidine and related substances; inhalants; sedatives, hypnotics, and anxiolytics; stimulants (including cocaine); and other (or unknown) substances

Psychotic disorders can occur in association with withdrawal from the following classes of substances

Alcohol; sedatives, hypnotics, and anxiolytics; and other (or unknown) substances

Between 7% and 25% of individuals presenting with a first episode of psychosis in different settings are reported to have substance medication-induced psychotic disorder

True

Psychotic Disorder Due to Another Medical Condition

A: Prominent hallucinations or delusions

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

Specify if: with delusions and/or hallucinations

Specify current severity

Catatonia Associated with Another Mental Disorder (Catatonia Specifier)

A: The clinical picture is dominated by thee (or more) of the following symptoms:

1. Stupor

2. Catalepsy

3. Waxy flexibility

4. Mutism

5. Negativism

6. Posturing

7. Mannerism

8. Stereotypy

9. Agitation

10. Grimacing

11. Echolalia

12. Echopraxia

Catatonia Disorders Due to Another Medical Condition

A: The clinical picture is dominated by thee (or more) of the following symptoms:

1. Stupor

2. Catalepsy

3. Waxy flexibility

4. Mutism

5. Negativism

6. Posturing

7. Mannerism

8. Stereotypy

9. Agitation

10. Grimacing

11. Echolalia

12. Echopraxia

B: There is evidence from the history, physical exam, or lab 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

Manic 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 1 week and present most of the day, nearly every day

B: During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (feels rested after 3h sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (attention too easily drawn), as reported or observed

6. Increase in goal-directed activity

7. Excessive involvement in activities that have a high potential for painful consequences

C: The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

D: The episode is not attributable to the physiological effects of a substance

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 1 week and present most of the day, nearly every day

B: During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior

1. Inflated self-esteem or grandiosity

2. Decreased need for sleep (feels rested after 3h sleep)

3. More talkative than usual or pressure to keep talking

4. Flight of ideas or subjective experience that thoughts are racing

5. Distractibility (attention too easily drawn), as reported or observed

6. Increase in goal-directed activity

7. Excessive involvement in activities that have a high potential for painful consequences

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 choice

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

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

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (Ex: feels sad, empty, or hopeless) or observation made by others

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3. Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day

4. Insomnia or hypersomnia nearly every day

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

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day

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

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

Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder

True

Bipolar I Disorder

A: Criteria have been met for at least one manic episode

B: At least one manic episode is not better explained by schizoaffective disorder and not superimposed on schizophrenia, schizophreniform disorder, delusion disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder

Specify if: with various feelings/pattern

Bipolar II Disorder

A: Criteria have been met for at least one hypomanic episode and at least one major depressive episode

B: There has never been a manic episode

C: At least one hypomanic episode and at least one major depressive episode are not better explained by schizoaffective disorder and are not superimposed on schizophrenia 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 if: current or recent depressed/hypomanic

Specify if: with various distresses/remission/severity

Bipolar II Disorder Association with Thoughts or Behavior

About 1/3 of individuals with bipolar II disorder report a lifetime history of suicide attempt. Risk and incidence of attempted suicide in bipolar II and bipolar I disorder appear to be similar

Cyclothymic Disorder

A: For at least 2 years (at least 1 in children) 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 in children), Criterion A symptoms 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 or another medical condition

F: The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Specify if: With anxious distress

Prevalence of cyclothymic disorder

The lifetime prevalence of cyclothymic disorder in the U.S. and Europe is approximately .4-2.5%.

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 abnormally elevated, expansive, or irritable mood and abnormally increased activity or energy

B: There is evidence from the history, physical exam, or lab findings of both (1) and (2)

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication

2. 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

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: onset during intoxication/withdrawal/after medication use

Disruptive Mood Dysregulation Disorder

A: Severe recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation or provocation

B: The temper outbursts are inconsistent with development level

C: The temper outbursts occur, on average, three or more times a 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: 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

F: Criteria A and D are present in at least two of three settings and are severe in at least one of them

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

J: The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder

K: The symptoms are not attributable to the physiological effects of a substance or another medical or neurological condition

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

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (feeling sad or empty), or observation made by others

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

3. Significant weight loss when not dieting or weight gain

4. Insomnia or hypersomnia every day

5. Psychomotor agitation or retardation nearly every day

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day

9. Recurrent thoughts of death, 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 another medical condition

D: At least one major depressive episode is not better explained by any schizo disorder or other psychotic disorders

E: There has never been a manic episode or a hypomanic episode

Specify if: Type of features/pattern

Persistent Depressive 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

B: Presence, while depressed, of two (or more) of the following

1. Poor appetite or overeating

2. Insomnia or hypersomnia

3. Low energy or fatigue

4. Low self-esteem

5. Poor concentration or difficulty making decisions

6. Feelings of hopelessness

C: During the 2 year period (1 year for children) 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

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 or another medical condition

H: The symptoms cause clinically significant distress or impairment in important areas of functioning

Specify if: Anxious distress/features/level of remission/level of onset/amount of episodes

Depressive Disorder Due to Another Medical Condition

A: A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized by depressed mood or markedly diminished interest or pleasure in all, or almost all, activities

B: There is evidence from the history, physical exam, or lab 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

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:

1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment issues

2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness or injury

3. Persistent and excessive worry about experiencing an untoward event that causes separation from a major attachment figure

4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation

5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings

6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure

7. Repeated nightmares involving the theme of separation

8. Repeated complaints of physical symptoms 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 disorder; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety; or concerns about having an illness in illness anxiety disorder

Selected Mutism

A: Consistent failure to speak in specific social situations in which there is an expectation for speaking 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 communicative disorder and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder

Specific Phobia

A: Marked fear or anxiety about a specific object or situation

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 6 months or more

F: The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas in 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; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations

Specify if: type of phobic stimulus and situational/other

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, being observed, and performing in front of others

B: The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated

C: The social situations almost always provoke fear or anxiety

D: The social situations are avoided or endured with intense fear or anxiety

E: The fear or anxiety is out 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 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 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 dysmorphic disorder, or autism spectrum disorder

J: If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive

Specify if: Performance only

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

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. Chills or heat sensations

10. Paresthesias

11. Derealization or depersonalization

12. Fear of losing control or “going crazy”

13. Fear of dying

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

1. Persistent concern or worry about additional panic attacks or their consequences

2. A significant maladaptive change in behavior related to the attacks

C: The disturbance is not attributable to the physiological effects of a substance or another medical condition

D: The disturbance is not better explained by another mental disorder

Agoraphobia

A: Marked fear or anxiety about two (or more) of the following five situations

1. Using public transportation

2. Being in open spaces

3. Being in enclosed places

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

C: The agoraphobia situations almost always provoke fear or anxiety

D: The agoraphobia 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 agoraphobia situations and to the sociocultural context

F: The fear, anxiety, or avoidance is persistent, typically lasting 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 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

Generalized Anxiety Disorder

A: Excessive anxiety and worry, 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)

1. Restlessness or feeling keyed up or on edge

2. Being easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance

D: The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in important areas of functioning

E: The disturbance is not attributable to the physiological effects of a substance or another medical condition

F: The disturbance is not better explained by another mental disorder

Facts about Generalized Anxiety Disorder

Around 60-66% of those diagnosed are women.

It is associated with increased suicidal thoughts and behaviors.

Obsessions

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress

   1. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action

Compulsions

1. Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly

2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive

Obsessive Compulsive Disorder

A: Presence of obsessions, compulsions, or both

B: The obsessions or compulsions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C: The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance or another medical condition

D: The disturbance is not better explained by the symptoms of another mental disorder

Specify if: Type of insight/beliefs and if tic-related

Up to 30% of individuals with OCD have a lifetime tic disorder

True

Prevalence and Association with Suicidal Thoughts or Behavior of OCD

The 12 month prevalence of OCD in the U.S. is 1.2%, with similar rates across the globe

A mean rate of lifetime suicide attempts of 14.2%, a mean rate of lifetime suicidal ideation of 44.1%

Body Dysmorphic Disorder

A: Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

B: At some point during the course of the disorder, the individual has performed repetitive behaviors or mental acts in response to the appearance concerns

C: The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

D: The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

Specify if: With muscle dysmorphia/type of insight/delusional beliefs

Facts about Body Dysmorphic Disorder

Prevalence of body dysmorphic disorder (2.5% for women and 2.2% in men).

Mean age at disorder onset is 16-17 years

Four times more likely to have experienced suicidal thoughts and 2.6 times more likely to have made suicide attempts compared with healthy control subjects and individuals diagnosed with ED, OCD, or any anxiety disorder

Hoarding Disorder

A: Persistent difficulty discarding or parting with possessions, regardless of their actual value

B: This difficulty is due to a perceived need to save the items and to distress associated with discarding them

C: The difficulty discarding possessions in the accumulation of possessions that congest and clutter active living areas and substantially comprises their intended use. If living areas are uncluttered, it is only because of the interventions of their parties (family/cleaners)

D: The hoarding causes clinically significant distress or important in important areas of functioning

E: The hoarding is not attributable to another medical condition

F: The hoarding is not better explained by the symptoms of another mental disorder

Specify if: Excessive acquisition/type of insight/delusional beliefs

Trichotillomania (Hair-Pulling Disorder)

A: Recurrent pulling out of one’s hair, resulting in hair loss

B: Repeated attempts to decrease or stop hair pulling

C: The hair pulling causes clinically significant distress or impairment in important areas of functioning

D: The hair pulling or hair loss is not attributable to another medical condition

E: The hair pulling is not better explained by the symptoms of another mental disorder

Excoriation (Skin-Picking Disorder)

A: Recurrent skin picking resulting in skin lesions

B: Repeated attempts to decrease or stop skin picking

C: The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

D: The skin picking is not attributable to the physiological effects of a substance or another medical condition

E: The skin picking is not better explained by symptoms of another mental disorder

Substance/Medication-Induced Obsessive/Compulsive and Related Disorder

A: Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture

B: There is evidence from the history, physical exam, or lab findings of both (1) and (2)

1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication

2. The involved substance/medication is capable of producing the symptoms in Criterion A

C: The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced

D: The disturbance does not occur exclusively during the course of a delirium

E: The disturbance causes clinically significant distress or impairment in important areas of functioning

Specify if: Onset during intoxication/withdrawal/after medication use

Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

A: Obsessions, compulsions, preoccupations with appearance, hoarding, skin-picking, hair pulling, or other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorder predominate in the clinical picture

B: There is evidence from the history, physical exam, or lab 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

Specify: Type of symptoms

Reactive Attachment Disorder

A: A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following

1. The child rarely or minimally seeks comfort when distressed

2. The child rarely or minimally responds to comfort when distressed

B: A persistent social and emotional disturbance characterized by at least two of the following

1. Minimal social and emotional responsiveness to others

2. Limited positive affect

3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers

C: The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults

2. Repeated changes of primary caregivers that limit opportunities to form stable attachments

3. Rearing in unusual settings that severely limit opportunities to form selective attachments

D: The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A

E: The criteria are not met for autism spectrum disorder

F: The disturbance is evident before age 5 years

G: The child has a developmental age of at least 9 months

Specify if: Persistent and current severity

Disinhibited Social Engagement Disorder

A: A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults

2. Overly familiar verbal or physical behavior

3. Diminished or absent checking back with adult caregivers after venturing away, even in unfamiliar settings

4. Willingness to go off with an unfamiliar adult with minimal or no hesitation

B: The behaviors in Criterion A are not limited to impulsivity but include socially disinhibited behavior

C: The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults

2. Repeated changes of primary caregivers that limit opportunities to form stable attachments

3. Rearing in unusual settings that severely limit opportunities to form selective attachments

D: The care in criterion C is presumed to be responsible for the disturbed behavior in Criterion A

E: The child has a developmental age of at least 9 months

Specify if: Persistent and current severity