DSM-5-TR

disruptive mood dysregulation disorder

1. Severe recurrent temper outbursts that are out of proportion to the situation

2. Outbursts are inconsistent with developmental level

3. ~3x a week or more

4. Outbursts occur most of the day, nearly every day, observable by others

5. 1-4 present for 12+ months - no period last 3 or more months without symptoms in 1-4

6. Older than 6, younger than 18. Onset is before 10

7. Behaviours do not exclusively occur in episode of major depression and are not better explained by another mental health disorder, or effects of a substance/physiological condition

8. Cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar. if criteria are met for ODD or IED and DMDD, DMDD diagnosis should be given.

differential diagnoses for disruptive mood dysregulation disorder

1. Bipolar disorders: bipolar I and II disorder manifest as an episodic illness with discrete episodes of mood perturbation. In contrast, disruptive mood dysregulation disorder is persistent and present over many months. Another differentiator is the former have the presence of elevated mood and grandiosity.

2. Oppositional defiant disorder: DMDD features persistent and intense outburst where as ODD is an everyday pattern of argumentativeness not always seen with as extreme explosiveness. If the criteria of ODD and DMDD are both met, a diagnosis of DMDD is given.

3. ADHD, major depressive disorder, anxiety disorders, and ASD: DMDD can be co-morbid with these, however if the irritability is only present in the context of another disorder that one of those diagnoses should be given

4. Intermittent explosive disorder: does not require individual’s mood to be persistently irritable or angry between outbursts like in DMDD. IED diagnosis can be made after 3 months of persistent symptoms, whereas DMDD is after 12, so these two diagnoses should not be made in the same child, DMDD diagnosis if criteria is met for both.

premenstrual dysphoric disorder

A. in the majority of menstrual cycles, at least 5 symptoms are 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 are present:

• marked affective lability (e.g. mood swings, suddenly sad, 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 on edge

C. One or more of the following symptoms must be additionally present, to reach a total of 5 symptoms when combined with B:

• decreased interest in usual activities

• subjective difficulty concentrating

• lethargy

• change in appetite, overeating, specific food cravings

• hypersomnia or insomnia

• overwhelmed or out of control

• physical symptoms (e.g. breast tenderness or swelling, joint/muscle pain, bloating or weight gain)

D. clinically significant distress or interference with functioning

E. criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles

differential diagnosis for premenstrual dysphoric disorder

• premenstrual syndrome: premenstrual syndrome does not require minimum of 5 symptoms nor mood-related symptomatology, considered less severe and more common than premenstrual dysphoric disorder. presence of somatic or behavioural symptoms without the required affective symptoms likely meet criteria for premenstrual syndrome.

• dysmenorrhea: a syndrome of painful menses, distinct from a syndrome characterized by affective changes. dysmenorrhea begins with onset of menses, whereas premenstrual dysphoric disorder begins before onset of menses

• hormonal treatments: if symptoms occur after initiation of exogenous hormone use, the symptoms may be attributable to use of hormones (e.g. substance/medication-induced depressive disorder), rather than underlying condition of premenstrual dysphoric disorder

substance/medication-induced depressive disorder

A. depressed mood or markedly diminished interest in all, or almost all, activities that predominates clinical picture

B. evidence from history, physical exam, or laboratory finding of both:

1. symptoms in A developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from meds

   1. depression is common for withdrawal, assess if depressive symptoms are present outside the window of withdrawal (~4 weeks)

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

C. not better explained by another depressive disorder (i.e. symptoms preceded use of substance/medication, symptoms persistent after cessation of use, etc.)

D. disturbance does not exclusively occur during course of delirium

E. causes clinically significant distress or impairment

recording procedures for substance/medication-induced depressive disorder

• begins with specific substance that is presumed to be causing depressive symptoms

• code use based on criteria table

• e.g. F14.24 severe cocaine use disorder with cocaine-induced depressive disorder, with onset during withdrawal.

• when multiple substances are judged to be playing a role in onset of depressive symptoms, each should be listed separately

differential diagnosis for substance/medication-induced depressive disorder

• substance intoxication and withdrawal: depressive symptoms occur commonly in substance intoxication and withdrawal. a diagnosis of substance-induced depressive disorder should be made when mood symptoms are sufficiently severe to warrant clinical attention

• independent depressive disorder: in substance/medication-induced disorder, a substance is taken in high enough amounts to be possibly etiologically related to symptoms, if the depressive syndrome is observed at other times, it should be diagnosed as an independent depressive disorder

• depressive disorder due to another medical condition: because those with medical conditions often take meds, the clinician must consider if the depressive symptoms are due to the meds or the physiological consequences of the condition. history often serves as a primary basis for judgment. sometimes, a change in meds can help empirically decide if meds are the causative agent. both diagnoses can be given. if neither can be determined, a diagnosis of specified or unspecified depressive disorder is indicated

depressive disorder due to another medical condition

A. prominent and persistent disturbance in mood, depressed or markedly diminished interest, that predominates in clinical picture

B. evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition

C. disturbance is not better explained by another mental disorder

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

E. causes clinically significant distress or impairment

differential diagnosis for depressive disorder due to another medical condition

• depressive disorders not due to another medical condition: determination of whether the medical condition is causing the disorder depends on a) absence of depressive episodes prior to medical condition, b) probability that the associated medical condition can cause depressive disorder, c) depressive symptoms start after onset or worsening of medical condition, especially if the depressive symptoms remit once the medical condition is treated

• adjustment disorder: the onset of a medical condition is in itself a life stressor that could bring on either an adjustment disorder or episode of major depression. differentiating elements are pervasiveness of depressive picture and the number and quality of depressive symptoms that individual report on mental status examination

• demoralization: common reaction to chronic medical illness. lacks anhedonia associated with depressive disorder due to another medical condition, and individuals can still experience moments of happiness and find it in meaningful activities

other specified depressive disorder

applies to presentations in which symptoms cause significant distress or impairment of function but do not meet criteria of any disorders in the depressive disorders diagnostic class and do not meet criteria for adjustment disorder. used when clinician choose to communicate specified reason that the presentation does not meet criteria for any specific depressive disorder. examples:

1. recurrent brief depression: concurrent presence of depressed mood and at least 4 other symptoms for 2-13 days at least once a month for 12 consecutive months in an individual who never met criteria for any other depressive, bipolar, of psychotic disorder

2. short-duration depressive episode (4-13 days): depressed affect and 4/8 symptoms of a major depressive episode persists between 4-13 days in an individual who never met criteria for any other depressive, bipolar, of psychotic disorder

3. depressive episode with insufficient symptoms: depressed affect and at least 1/8 symptoms of a major depressive episode causing distress or impairment for at least 2 weeks in an individual who never met criteria for any other depressive, bipolar, of psychotic disorder

4. major depressive episode superimposed on a psychotic disorder

unspecified depressive disorder

applies to presentations in which symptoms cause significant distress or impairment of function but do not meet criteria of any disorders in the depressive disorders diagnostic class and do not meet criteria for adjustment disorder. used in situations when clinician chooses not to specify reason criteria are not met for a specific depressive disorder, and includes presentations for which there is insufficient info (e.g. in emergency room settings)

unspecified mood disorder

applies to presentations in which symptoms characteristic of a mood disorder that causes distress or impairment of function but do not at time of evaluation meet full criteria for either bipolar or depressive disorders and it is difficult to choose between unspecified bipolar and related disorder and unspecified depressive disorder

severity specifiers

• 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

fear vs anxiety

fear is more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviours

anxiety is more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviours

anxiety disorders

• share features of excessive fear and anxiety

• differ from one another in the types of objects or situations that induce fear, anxiety, or avoidance behaviour, and the associated cognition

• excessive and persistent beyond developmentally appropriate periods

• most develop in childhood and tend to persist if not treated

• 2:1 ratio of girls to boys

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 3 of the following:

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

2. Persistent and excessive worry about losing major attachment figures or possible harm to them

3. Persistent and excessive worry about experiencing an untoward event (e.g. kidnapping, getting lost, becoming ill) that causes separation from attachment figure

4. Persistent reluctance to go out, away from home, because of fear of separation

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

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

7. Repeated nightmares involving the theme of separation

8. Repeated complaints of physical symptoms when separation occurs or is anticipated

B. Lasts at least 4 weeks in children and adolescents and typically 6 months or more in adults.

C. Significant distress or impairment in areas of functioning

D. Disturbance is not better explained by another mental disorder (ASD, psychotic disorders, agoraphobia, generalized anxiety disorder, illness anxiety disorder)

Development and Course: onset may be as early as preschool age and may occur any time during childhood and adolescence. Median age onset reported by adults in late adolescence and in the mid-20s. Periods of exacerbation and remission; majority of children with separation anxiety disorder are free of impairing anxiety disorders over their lifetime.

differential diagnosis for separation anxiety disorder

GAD, panic disorder, agoraphobia, conduct disorder, social anxiety disorder, PTSD, illness anxiety disorder, prolonged grief disorder, ODD, psychotic disorders, personality disorders

differential diagnosis for separation anxiety disorder: GAD

distinguishable from separation anxiety disorders which concerns separation from attachment figures

differential diagnosis for separation anxiety disorder: panic disorder

in this disorder, panic attacks occur unexpectedly and are usually accompanied by fears of dying or going “crazy”, the panic attacks seen in separation anxiety disorder occur in anticipation imagined or real separation from attachment figures or from worries of untoward events befalling them

differential diagnosis for separation anxiety disorder: agoraphobia

unlike individuals with agoraphobia, those with separation anxiety disorder are not anxious about being trapped or incapacitated in situations from which escape is perceived as difficult in the event of panic-like symptoms or other incapacitating symptoms

differential diagnosis for separation anxiety disorder: conduct disorder

school avoidance is common in conduct disorder but anxiety is not responsible for school absences. usually stays away from, rather than returns to, the home

differential diagnosis for separation anxiety disorder: social anxiety disorder

school refusal is also common, however it is due to fear of being judged negatively by others

differential diagnosis for separation anxiety disorder: PTSD

fear of separation from loved ones is common after a traumatic event. in PTSD, central symptoms concern intrusions about or avoidance of the memories association with the traumatic event itself

differential diagnosis for separation anxiety disorder: illness anxiety disorder

individuals worry about specific medical illnesses they themselves may have, not about them being separated from close attachments via their health and wellbeing

differential diagnosis for separation anxiety disorder: prolonged grief disorder

intense longing for the deceased, intense emotional pain, preoccupation with the deceased or circumstances of death are expected responses in this disorder, whereas fear of separation from attachment figures is central in separation anxiety disorder

differential diagnosis for separation anxiety disorder: ODD

should only be considered when there is persistent oppositional behaviour unrelated to the anticipation or occurrence of separation from attachment figures

differential diagnosis for separation anxiety disorder: psychotic disorders

unlike the hallucinations in psychotic disorders, the unusual perceptual experiences that may occur in separation anxiety disorder are usually based on a misperception of an actual stimulus, occur only in certain situations (e.g., nighttime), and are reversed by the presence of an attachment figure

differential diagnosis for separation anxiety disorder: personality disorders

dependent personality disorder is characterized by indiscriminate tendency to rely on others, whereas separation anxiety disorders involves concern about the proximity and safety of attachment figures. borderline personality disorder is characterized by fear of abandonment by loved ones, but problems in identity, self-direction, interpersonal functioning, and impulsivity are additionally central to that disorder

selective 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/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 and does not exclusively occur during the course of ASD, schizophrenia, or another psychotic disorder

Development and Course: Onset is usually before the age of 5, longitudinal course is largely unknown. In most cases, selective mutism may fade, but symptoms of social anxiety disorder often remain.

differential diagnosis for selective mutism

• silent period in immigrant children learning a second language

• communication disorders: speech disturbance in these conditions is not restricted to a specific social situation

• neurodevelopmental disorders and schizophrenia and other psychotic disorders: all of these may have problems in social communication. in contrast, selective mutism should only be diagnosed when a child has an established capacity to speak in some social situations (e.g., typically at home)

• social anxiety disorder: the social anxiety and social avoidance in social anxiety disorder may be associated with selective mutism. In such cases, both diagnoses may be given. highly co-morbid (~80% of the time)

panic attack specifier

an abrupt surge of intense fear or 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. Chills 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.

differential diagnosis for panic attacks

• other paroxysmal episodes (e.g. “anger attacks”): panic attacks should not be diagnosed if the episodes do not involve the essential feature of an abrupt surge of intense fear or intense discomfort, but rather other emotional states (e.g. anger, grief)

• anxiety disorder due to another medical condition: medical conditions that can cause or be misdiagnosed as panic attacks include hyperthyroidism, hyperparathyroidism, pheochromocytoma, vestibular dysfunctions, seizure disorders, and cardiopulmonary conditions

• substance/medication-induced anxiety disorder: intoxication with CNS stimulants or cannabis and withdrawal from CNS depressants can precipitate a panic attack. detailed history should be taken to see if the panic attacks occurred prior to excessive substance use.

• panic disorder: repeated unexpected panic attacks are required alongside full diagnostic criteria

substance/medication-induced anxiety disorder

A. panic attacks or anxiety is predominant in the clinical picture

B. Evidence of:

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

2. the substance/medication is capable of producing the symptoms in criterion A

C. the disturbance is not better explained by another anxiety disorder. such evidence of an independent anxiety disorder could include the following:

• symptoms precede the onset of substance/medication use; the symptoms persist for a long time after cessation of acute withdrawal or severe intoxication; or there is other evidence of an independent anxiety disorder

D. disturbance does not occur exclusively during the course of delirium

E. symptoms cause clinically significant distress or impairment in functioning

Specify:

With onset during intoxication: If 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.

With onset after medication use: If symptoms developed at initiation of medication, with a change in use of medication, or during withdrawal of medication

differential diagnosis for substance/medication-induced anxiety disorder

• substance intoxication or withdrawal: what symptoms are predominating the clinical picture

• independent anxiety disorder: are the anxiety symptoms observed at times other than during substance/medication use

• delirium: if symptoms only occur in the course of delirium, then do not apply the diagnosis

• anxiety disorder due to another medical condition: a detailed history to see if its the medical condition vs medication as the causative agent. both diagnoses can be used

anxiety disorder due to another medical condition

A. panic attacks or anxiety is predominant in the clinical picture

B. evidence that the disturbance is the direct pathophysiological consequence of another medical condition

C. not better explained by another mental disorder

D. does not exclusively occur during course of delirium

E. disturbance causes clinically significant distress or impairment in functioning

differential diagnosis for anxiety disorder due to another medical condition

• delirium and major or mild neurocognitive disorder: separate diagnosis, not given if the anxiety disturbance occurs exclusively during the course of a delirium. however, a diagnosis of anxiety disorder due to another medical condition may be given in addition to a diagnosis of major mild neurocognitive disorder if the anxiety is judged to be a physiological consequence of the pathological process causing the neurocognitive disorder and if anxiety is a prominent part of the clinical presentation

• mixed presentation of symptoms: if the presentation includes a mix of different types of symptoms, the specific mental disorder due to another medical condition depends on which symptoms predominate in the clinical picture

• substance/medication-induced anxiety disorder: certain medications are new and increasing anxiety, and when this is the case, the medication may be the most likely etiology, although it may be difficult to distinguish. both diagnoses can be given.

• anxiety disorder (not due to a known medical condition): no specific and direct causative physiological mechanisms associated with another medical condition can be demonstrated

• illness anxiety disorder: illness anxiety disorder is characterized by worry about illness, concern about pain, and bodily preoccupations. In the case of illness anxiety disorder, individuals may or may not have diagnosed medical conditions. Although an individual with illness anxiety disorder and a diagnosed medical condition is likely to experience anxiety about the medical condition, the medical condition is not physiologically related to the anxiety symptom

• adjustment disorders: warranted when individuals experience a maladaptive response to the stress of being diagnosed with or having the manage a medical condition. the reaction to stress usually concerns the meaning and consequences of the medical condition, in contrast with the experience of anxiety or mood symptoms that occur as a physiological consequence of the medical condition. in adjustment disorder, being anxiety symptoms are typically related to coping with the stress of having the medical and condition, whereas in anxiety disorder due to another medical condition individuals are more likely to have prominent physical symptoms and to be focused on issues other than the stress of the illness itself

other specified anxiety disorder

applies to presentations in which symptoms characteristic of an anxiety disorder are present but full criteria is not met. used when clinicians choose to communicate the specific reason the presentation does not meet the criteria for a specific anxiety disorder. examples:

1. limited-symptom attacks

2. generalized anxiety occurring less often than “more days than not”

3. Khyâl cap (wind attacks)

4. Ataque de nervios (attack of nerves)

unspecified anxiety disorder

applies to presentations in which symptoms characteristic of an anxiety disorder are present but full criteria is not met.used in situations when clinician chooses not to specify the reason that they criteria are not met for a specific anxiety disorder (e.g. emergency room settings)

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 behaviours or mental acts in response to the appearance concerns

C. The preoccupation causes clinically significant distress or impairment in 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: the individual is preoccupied with the idea that their body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas (e.g. skin or hair), which is often the case. Almost exclusively in men or adolescent boys.

• With good or fair insight

• With poor insight

• With absent insight/delusional beliefs

Development and course: most common age of onset is 12-13 years; in 2/3 of individuals onset is before 18. Subclinical concerns usually evolve into the full disorder. Tends to be chronic, improvement is likely when treatment received.

differential diagnosis for body dysmorphic disorder

• Normal appearance concerns and clearly noticeable physical defects: differs from normal appearance concerns in being characterized by excessive appearance-related preoccupations and repetitive behaviours that are time-consuming, usually difficult to resist or control, cause clinically significant distress or impairment. Physical defects that are clearly noticeable are not diagnosed as body dysmorphic disorder. However, if the physical defect was caused by the disorder, diagnosis should be given

• Eating disorders: in individuals with an eating disorder, concerns about being fat or overweight are considered a symptom of the eating disorder rather than body dysmorphic disorder. Can be co-morbid.

• Other obsessive-compulsive and related disorders: body dysmorphic disorder preoccupations and repetitive behaviours focus on physical appearance. When skin picking or hair removal is intended to improve the appearance of perceived skin defects, body dysmorphic disorder, rather than excoriation disorder or trichotillomania, is diagnosed.

• Illness anxiety disorder: individuals with body dysmorphic disorder are not preoccupied with having or acquiring a serious illness and in clinical samples do not have particularly elevated levels of somatization.

• Major depressive disorder: prominent preoccupation with appearance and excessive repetitive behaviours in body dysmorphic disorder differentiate it from major depressive disorder.

• Anxiety disorders: Unlike social anxiety disorder, agoraphobia, and avoidant personality disorder, body dysmorphic disorder includes prominent appearance-related preoccupation, which may be delusional, and repetitive-behaviours. In addition, the social anxiety and avoidance that are characteristic of body dysmorphic disorder are attributable to concerns about perceived appearance defects and the belief or fear that other people with consider these individuals ugly, or ridicule/reject them because of their physical features. Unlike generalized anxiety disorder, anxiety and worry in body dysmorphic disorder focus on perceived appearance flaws.

• Psychotic disorders: body dysmorphic disorder with delusional beliefs is diagnosed as is with absent insight/delusional beliefs, not as delusional disorder. Body dysmorphic disorder does not have disorganized behaviour and other psychotic symptoms are absent.

• Other disorders and symptoms: body dysmorphic disorder should not be diagnosed if the preoccupation is limited to discomfort with or a desire to be rid of one’s primary and/or secondary sex characteristics in an individual with gender dysphoria. Nor should it be diagnosed if the preoccupation focuses on the belief that one emits a foul or offensive body odour as in olfactory reference disorder (an other specified obsessive-compulsive and related disorder). Body integrity disorder involves persistent desire to become an amputee in order to correct mismatch between individual’s sense of body configuration and actual anatomical configuration. Koro, a culturally related disorder that occurs in epidemics in Southeast Asia consists of fear that genitals is shrinking or retracting into abdomen, often accompanied by belief that death with result. Preoccupation is with the death rather than perceived ugliness.

hoarding disorder

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

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

C. Results in accumulation of possessions that congestion and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties.

Specify if:

• With excessive acquisition: if difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Approx. 80-90% of individuals display this specifier.

• With good or fair insight

• With poor insight

• With absent insight/delusional beliefs

Development and course: may first emerge around 15-19 years, start interfering with everyday functioning by mid-20s, and cause clinically significant impairment by mid-30s. Severity of hoarding increases with each decade of life. Often chronic.

differential diagnosis for hoarding disorder

• Other medical conditions: not diagnosed if symptoms are a direct medical consequence of another medical condition. Damage to anterior ventromedial prefrontal and cingulate cortices have been associated with excessive accumulation of objects. In this individuals, hoarding would not be present prior to onset of brain damage.

• Neurodevelopmental disorders: should not be diagnosed if accumulation of objects is a consequence of a neurodevelopmental disorder

• Schizophrenia spectrum and other psychotic disorders: should not be diagnosed if accumulation of objects is a direct consequence of delusions or negative symptoms

• Major depressive disorder: should not be diagnosed if accumulation of objects is a direct consequence of psychomotor retardation, fatigue, loss of energy during a major depressive episode

• OCD: should not be diagnosed if accumulation of objects is a direct consequence of typical obsessions or compulsions. Feelings of incompleteness are the most frequent OCD symptoms associated with this form of hoarding. In OCD, the behaviour is unwanted and distressing, and the individual does not experience pleasure or reward from it. Excessive acquisition should stem from a genuine desire to possess items. Individuals who hoard in the context of OCD will more likely accumulate bizarre items. When severe hoarding appears concurrently with other typical symptoms of OCD but is judged to be independent from these symptoms, both hoarding disorder and OCD may be diagnosed

• Neurocognitive disorders: should not be diagnosed if accumulation of objects is a direct consequence of a degenerative disorder. Typically, onset of accumulating behaviour is gradual and follows onset of neurocognitive disorder and accompanied by self-neglect and severe domestic squalor, alongside other neuropsychiatric symptoms.

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.

Development and course: onset most commonly coincides with or follows puberty. Usually chronic. Symptoms may worsen in females premenstrually but not consistently during pregnancy.

differential diagnosis for trichotillomania

• Normative hair removal/manipulation

• Other obsessive-compulsive and related disorders: individuals with OCD and symmetry concerns may pull out hairs as part of their symmetry rituals, and individuals with body dysmorphic disorder may remove body hair that they perceive as ugly or abnormal; in such cases a diagnosis of trichotillomania is not given.

• Psychotic disorder: individuals with psychotic disorder may remove hair in response to a delusion or hallucination. Trichotillomania is not diagnosed in such cases.

• Another medical condition: trichotillomania is not diagnosed if the hair pulling or loss is attributable to another medical condition.

• Substance-related disorders: hair-pulling symptoms may be exacerbated by certain substances–for example, stimulants–but is less likely that substances are the primary cause of persistent hair pulling.

excoriation (skin-picking) disorder

A. Recurrent skin picking resulting in skin lesions

B. Repeated attempts to decrease or stop skin picking

Development and course: presents at various ages, the skin picking most often has onset during adolescence, commonly coinciding with or following puberty. Frequently begins with a dermatological condition, such as acne. Usually chronic.

differential diagnosis of excoriation disorder

• Psychotic disorder: skin picking may occur in response to a delusion or tactile hallucination in psychotic disorder. In such cases, excoriation disorder should not be diagnosed.

• Other obsessive-compulsive and related disorders: excessive washing compulsions in OCD may lead to skin lesions, and skin picking may occur in individuals with body dysmorphic disorder who pick skin because of appearance concerns; in such cases, excoriation disorder should not be diagnosed.

• Neurodevelopmental disorders: while stereotypic movement disorder may be characterized by repetitive self-injurious behaviour, onset is in the early developmental period. Tics in individuals with Tourette’s disorder may lead to self-injury, the behaviour is not tic-like in excoriation disorder.

• Dermatitis artefacta (“factitious dermatitis”): used in dermatology to refer to medically unexplained, presumably self-induced skin lesions, that the individual denies any role in creating. In cases where there is evidence of deception, it can be malingering (if it is motivated by external incentives) or factitious disorder (if occurs in absence of external rewards). In the absence of deception, excoriation disorder can be diagnosed if there are repeated attempts to decrease or stop picking.

• Other disorders: excoriation disorder should not be diagnosed if the skin picking is primarily attributable to nonsuicidal self-injury.

• Other medical conditions: not be diagnosed in attributable another medical condition. Excoriation disorder may be precipitated or exacerbated by an underlying dermatological condition. The differentiation between these two clinical situations (acne with some scratching and picking vs. acne with comorbid excoriation disorder) requires an assessment of the extent to which the individual’s skin picking has become independent of the underlying dermatological condition.

• Substance/medication-induced disorders: induced by certain substances (e.g. cocaine), excoriation disorder should not be diagnosed. If such skin picking is clinically significant, then a diagnosis of substance/medication-induced obsessive-compulsive and related disorder should be considered.

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 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 an obsessive-complusive and related disorder that is not substance/medication-induced. That is, symptoms precede onset of substance/medication use, persist after cessation of acute withdrawal or severe intoxication, or other evidence of an independent disorder.

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

Specify if:

• with onset during intoxication

• with onset during withdrawal

• with onset after medication use

differential diagnosis for substance/medication-induced obsessive-compulsive and related disorder

• Substance intoxication and substance withdrawal: a diagnosis of substance/medication-induced obsessive-compulsive and related disorder with onset during intoxication or withdrawal should be made instead only id the symptoms are judged to be in excess of those usually associated with intoxication or withdrawal and warrant clinical attention.

• Obsessive-compulsive and related disorder: consider onset, course, and other factors with respect to substances/medications. A primary obsessive-compulsive and related disorder diagnosis is warranted if the symptoms persist for a substantial period of time (~1 month+) after the end of substance intoxication or individual has history of an obsessive-compulsive and related disorder.

• Obsessive-compulsive and related disorder due to another medical condition

• Delirium

obsessive-compulsive and related disorder due to another medical condition

A. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, 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 examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

C. Not better explained by another mental disorder

D. Does not occur exclusively during the course of delirium

Specify if:

• with obsessive-compulsive disorder-like symptoms: if these symptoms predominate the clinical picture

• with appearance preoccupations

• with hoarding symptoms

• with hair-pulling symptoms

• with skin-picking symptoms

differential diagnosis for obsessive-compulsive and related disorder due to another medical condition

• delirium: diagnosis not given if disturbance occurs exclusively in delirium. can be given in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of obsessive-compulsive symptoms is judged to be a physiological consequence of the pathological process causing the dementia and if the symptoms are a prominent part of the clinical picture

• mixed presentation of symptoms (e.g., mood and obsessive-compulsive and related symptoms) judged to be due to another medical condition: the specific mental disorder due to another medical condition depends on which symptoms predominate the clinical picture

• substance/medication-induced obsessive-compulsive and related disorder

• obsessive-compulsive and related disorders (primary): in primary mental disorders, there is no specific and direct causative physiological mechanism

• illness anxiety disorder: illness anxiety disorder is characterized by a preoccupation with having or acquiring a serious illness. In the case of illness anxiety disorder, individuals may or may not have diagnosed medical conditions

• associated feature of another mental disorder

• other specified obsessive-compulsive and related disorder or unspecified obsessive-compulsive and related disorder: given when it’s unclear if symptoms are primary, substance-induced, or due to another medical condition

other specified obsessive-compulsive and related disorder

applies to presentations in which symptoms are characteristic of obsessive-compulsive and related disorder but do not meet full criteria and clinician is specifying why. examples:

1. body dysmorphic-like disorder with actual flaws: defects or flaws in physical appearance are clearly observable by others.

2. body dysmorphic-like disorder without repetitive behaviours

3. other body-focused repetitive behaviour disorder: presentations involving recurrent body-focused repetitive behaviours OTHER THAN hair pulling and skin picking that are accompanied by attempts to stop and causes clinically significant distress or impairment

4. obsessional jealousy: nondelusional preoccupation with partner’s perceived infidelity. preoccupations may lead to repetitive behaviours or mental acts in response to the infidelity concerns, cause distress or impairment, not better explained by another mental disorder

5. olfactory reference disorder: persistent occupation with the belief that they emit a foul body odour that is unnoticeable to others; in response to this preoccupation, they engage in repetitive and excessive behaviours .

6. shubo-kyofu: characterized by excessive fear of having a bodily deformity

7. koro: an episode of sudden and intense anxiety that the penis in males (or the vulva and nipples in females) will recede into the body, possibly leading to death

unspecified obsessive-compulsive and related disorder

applies to presentations in which symptoms are characteristic of obsessive-compulsive and related disorder but do not meet full criteria and clinician is not specifying why

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:

1. The symptoms in criterion A developed during or soon after substance/medication exposure or withdrawal

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

3. Not better explained by a bipolar or related disorder that in not substance/medication induced

4. Disturbance does not occur exclusively during the course of a delirium

5. Causes clinically significant distress or impairment

Specify if:

• with onset during intoxication

• with onset during withdrawal

• with onset after medication use

Development and course: In phencyclidine-induced mania, the initial presentation may be one of a delirium with affective features, which then becomes an atypically appearing manic or mixed manic state. This condition follows the ingestion or inhalation quickly, usually within hours or, at the most, a few days. In stimulant-induced manic or hypomanic states, the response is in minutes to 1 hour after one or several ingestions or injections. The episode is very brief and typically resolves over 1–2 days. With corticosteroids and some immunosuppressant medications, the mania usually follows several days of ingestion, and the higher doses appear to have a much greater likelihood of producing bipolar symptoms

Bipolar and Related Disorder Due to Another Medical Condition

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. Evidence of direct pathophysiological consequence of another medical condition

C. Not better explained by another mental disorder

D. Does not exclusively occurring during the course of a delirium

E. Causes clinically significant distress or impairment

Specify if:

• with manic features: full criteria are not met for 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 also present but do not dominate the clinical picture

Development and course: Usually onset is within the first weeks or month of onset of associated medical condition. However, this is not always the case, as a worsening or later relapse of the associated medical condition may precede the onset of the manic or hypomanic syndrome. The clinician must make a clinical judgment in these situations about whether the medical condition is causative, based on temporal sequence as well as plausibility of a causal relationship. Finally, the condition may remit before or just after the medical condition remits, particularly when treatment of the manic/hypomanic symptoms is effective.

differential diagnosis for bipolar and related disorder due to another medical condition

• delirium and major or mild neurocognitive disorder: separate diagnosis not given in case of delirium. however, a diagnosis of bipolar and related disorder due to another medical condition may be given in addition to a diagnosis of major or mild neurocognitive disorder if the mood disturbance is judged to be a physiological consequence of the pathological process causing the neurocognitive disorder and if symptoms of irritability or elevated mood are a prominent part of the clinical presentation

• symptoms of catatonia and acute anxiety: it is important to differentiate symptoms of mania from excited catatonic symptoms and from agitation related to acute anxiety states

• medication-induced depressive or manic symptoms: a medical condition may be treated with meds that induce depressive or manic symptoms.

other specified bipolar and related disorder

applies to presentations in which symptoms are characteristic of bipolar and related disorder and causes clinically significant distress or impairment but does not meet full criteria and clinician is specifying why. examples:

1. 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

2. Hypomanic episodes with insufficient symptoms 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 one or more episodes of hypomania that do not meet full symptomatic criteria (i.e., at least 4 consecutive days of elevated mood and one or two of the other symptoms of a hypomanic episode, or irritable mood and two or three of the other symptoms of a hypomanic episode). 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

3. Hypomanic episode without prior major depressive episode: one or more hypomanic episodes but not meeting full criteria for a major depressive or manic episode

4. Short-duration cyclothymia (less than 24 months): never meet full criteria for a major depressive, manic, or hypomanic episode but hypomanic and depressive symptoms persists over a period of less than 24 months. Symptoms present more days than not and individual has never been without symptoms for more than 2 months, and is causing clinically significant distress or impairment

5. Manic episode superimposed on n schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorder. Note: Manic episodes that are part of schizoaffective disorder do not merit an additional diagnosis of other specified bipolar and related disorder

unspecified bipolar and related disorder

applies to presentations in which symptoms are characteristic of bipolar and related disorder and causes clinically significant distress or impairment but does not meet full criteria and clinician is NOT specifying why

unspecified mood disorder

applies to presentations in which symptoms are characteristic of a mood disorder but do not meet full criteria in either the bipolar or depressive disorders diagnostic classes and it is difficult to choose between unspecified bipolar and related disorder and unspecified depressive disorder

pica

A. persistent eating of nonnutritive, nonfood substances over a period of at least 1 month

B. the eating behaviour is inappropriate to the developmental level of the individual

C. the eating behaviour is not part of a culturally supported or socially normative practice

D. if the eating behaviour occurs in the context of another mental disorder, it is sufficiently severe to warrant additional clinical attention

Specify if:

• In remission: after full criteria for pica were previously met, the criteria have not been met for a sustained period of time

Development and course: onset can occur throughout the life, but most common in childhood. Can occur in normally developing children, whereas in adults its usually in the context of another mental disorder

differential diagnosis for pica

• other mental health disorders: can occur, diagnosis of pica should only be given if the eating behaviour is sufficiently persistent and severe to warrant additional clinical attention

• anorexia nervosa: can include ingestion of nonnutritive, nonfood substances as a means of attempting to control appetite. in such cases when it is used primarily as a means of weight control, anorexia nervosa should be the primary diagnosis

• factitious disorder: may intentional ingest foreign objects as part of a pattern of falsification of physical symptoms. in such instances, there is an element of deception that is consistent with deliberate induction of injury or disease

• nonsuicidal self-injury and nonsuicidal self-injury behaviours in personality disorders: may swallow harmful items in the context of these disorders

rumination disorder

A. repeated regurgitation of food over a period of at least 1 month. regurgitated food may be re-chewed, re-swallowed, or spit out

B. repeated regurgitation is not attributable to associated gastrointestinal or other medical condition

C. eating disturbance does not exclusively occur during the course of anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder

D. if symptoms occur in context of another mental disorder, they are sufficiently severe to warrant additional clinical attention

Specify if:

• in remission: after full criteria was previously met, the criteria have not been met for a sustained period of time

Development and course: onset can occur in infancy, childhood, adolescence, or adulthood, In infants, the age of onset is between 3-12 months and remit spontaneously. Can have an episodic course or occur continuously until treated.

differential diagnosis for rumination disorder

• gastrointestinal conditions: differentiate from gastroesophageal reflux or vomiting in infants. rule out via history and clinical observation

• anorexia nervosa and bulimia nervosa: may also engage in regurgitation with subsequent spitting out of food as a means of disposing of ingested calories because of concerns about weight gain

avoidant/restrictive food intake disorder

A. an eating or feeding disturbance (e.g. lack of interest in eating or food; avoidance based on the sensory characteristics of food; etc.) is associated with at least one of the following:

1. significant weight loss (or failure to achieve expected weight gain in children)

2. significant nutritional deficiency

3. dependence on enteral feeding or oral nutritional supplements

4. marked interference with psychosocial functioning

B. the disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice

C. does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is not evidence of a disturbance in the way in which one’s body weight or shape is experienced

D. the eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. when it does occur in the context of another disorder, the severity exceeds that routinely associated with the condition or disorder and warrants clinical attention

Specify if:

• in remission

Development and course: most commonly develops in infancy or early childhood and may persist in adulthood. avoidance related to aversive consequences can arise at any age. food avoidance and restriction based on sensory aspects is relatively stable and long-standing.

differential diagnosis for avoidant/restrictive food intake disorder

other medical conditions, obsessive-compulsive and related disorder due to pediatric acute-onset neuropsychiatric syndrome, specific neurological/neuromuscular disorders, reactive attachment disorder, ASD, specific phobia/ social anxiety disorder/ other anxiety disorders, anorexia nervosa, obsessive-compulsive disorder, major depressive disorder, schizophrenia spectrum disorders, factitious disorder or factitious disorder imposed on another, developmentally normal behaviour

differential diagnosis for avoidant/restrictive food intake disorder: other medical conditions

a diagnosis of avoidant/restrictive food intake disorder requires that the disturbance of intake is beyond that directly accounted for by physical symptoms consistent with a medical condition; the eating disturbance may persist after being triggered by a medical condition following resolution of the condition. an additional diagnosis of avoidant/restrictive food intake disorder requires that the eating disturbance is the primary focus for intervention.

differential diagnosis for avoidant/restrictive food intake disorder: obsessive-compulsive and related disorder due to paediatric acute-onset neuropsychiatric syndrome (PANS)

characterized by abrupt, dramatic onset of obsessive-compulsive symptoms or severely restricted food intake, together a range of additional neuropsychiatric symptoms. acute-onset, late age onset, or atypical symptoms suggest need for assessment to rule out PANS

differential diagnosis for avoidant/restrictive food intake disorder: specific neurological/neuromuscular, structural, or congenital disorders and conditions associated with feeding difficulties

avoidant/restrictive food intake disorder can be diagnosed in individuals with such presentations as long as all diagnostic criteria are met

differential diagnosis for avoidant/restrictive food intake disorder: reactive attachment disorder

can lead to disturbance in the caregiver-child relationship that can affect feeding and the child’s intake. should only be diagnosed concurrently if criteria for both disorders is met and the feeding disturbance is the primary focus of the intervention

differential diagnosis for avoidant/restrictive food intake disorder: ASD

can present with rigid eating behaviours and heightened sensory activities. avoidant/restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and when the eating disturbance requires specific treatment

differential diagnosis for avoidant/restrictive food intake disorder: specific phobia, social anxiety disorder, and other anxiety disorders

specific phobia, other type includes “situations that may lead to choking or vomiting” and can result in food avoidance. In situations where the eating problems becomes the primary focus of clinical attention, avoidant/restrictive food intake disorder is an appropriate diagnosis. in social anxiety disorder, the individual may present with a fear of being observed by others while eating, which can also occur in avoidant/restrictive food intake disorder

differential diagnosis for avoidant/restrictive food intake disorder: anorexia nervosa

includes fear of gaining weight, persistent behaviour that interferes with weight gain, and disturbances in perception of their own body weight - features that are not present in avoidant/restrictive food intake disorder. the two disorders should not be diagnosed concurrently.

differential diagnosis for avoidant/restrictive food intake disorder: OCD

may present with avoidance or restriction of intake in relation to preoccupations with food or ritualized eating behaviour. avoidant/restrictive food intake disorder should only be diagnosed concurrently if all criteria are met for both disorders and when aberrant eating is a major aspect of clinical intervention

differential diagnosis for avoidant/restrictive food intake disorder: major depressive disorder

appetite may be affect to such an extent that individuals present with significantly restricted food intake. usually appetite loss and related reduction of intake abate with resolution of mood problems. avoidant/restrictive food intake disorder should only be diagnosed concurrently if all criteria are met for both disorders and the eating disturbance requires specific treatment

differential diagnosis for avoidant/restrictive food intake disorder: schizophrenia spectrum disorders

individuals may exhibit odd eating behaviours, avoidance of specific foods because of delusional beliefs, or other manifestations of avoidant or restrictive intake. avoidant/restrictive food intake disorder should only be diagnosed concurrently if all criteria are met for both disorders and the eating disturbance requires specific treatment

differential diagnosis for avoidant/restrictive food intake disorder: factitious disorder or factitious disorder imposed on another

in order to assume the sick role, some individuals with factitious disorder may intentionally describe diets more restrictive than they are able to consume, and associated complications like need for nutritional supplements or enteral feedings. the presentation may be dramatic, and symptoms reported inconsistently. in factitious disorder imposed on another, the caregiver describes symptoms consistent with avoidant/restrictive food intake disorder and may induce physical symptoms. Need to differentiate between these and avoidant/restrictive food intake disorder through careful, comprehensive assessment

differential diagnosis for avoidant/restrictive food intake disorder: developmentally normal behaviour

some toddlers and children transiently narrow the variety of foods they are willing to eat, usually resolves spontaneously without intervention. avoidant/restrictive food intake disorder only applies if the picky eating leads to failure to meet appropriate nutritional needs or produce significant impairment in functioning

other specified feeding or eating disorder

applies to presentations in which symptoms are characteristic of a feeding and eating disorder that causes clinically significant distress or impairment but do not meet full criteria and clinician is specifying why. examples:

1. atypical anorexia nervosa: all criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range.

2. bulimia nervosa (of low frequency and/or limited duration): all criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviours occur, on average, less than once a week and/or for less than 3 months

3. binge-eating disorder (of low frequency and/or limited duration): all of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months

4. purging disorder: recurrent purging behaviour to influence weight or shape in the absence of binge eating

5. night eating syndrome: recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. there is awareness and recall of the eating. the night eating is not better explained by external influences and causes significant distress and/or impairment. the disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder.

unspecified feeding or eating disorder

applies to presentations in which symptoms are characteristic of a feeding and eating disorder that causes clinically significant distress or impairment but do not meet full criteria and clinician is NOT specifying why

oppositional defiant disorder

A. A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness lasting at least 6 months as evidenced by at least 4 symptoms from the following categories, and exhibited during interactions with at least one individual who is not a sibling.

Angry/Irritable Mood:

1. Often loses temper

2. Is often touchy or easily annoyed

3. Is often angry and resentful

Argumentative/Defiant Behaviour

4. Often argues with authority figures or, for children and adolescents, with adults

5. Often actively defies or refuses to comply with requests from authority figures or with rules

6. Often deliberately annoys others

7. Often blames others for their mistakes

Vindictiveness:

8. Has been spiteful or vindictive at least twice within the past 6 months

B. The disturbance in behaviour is associated with distress in the individual or others in their immediate social context or it impacts negatively on areas of functioning.

C. The behaviours do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, criteria are not met for disruptive mood dysregulation disorder

Specify current severity:

• mild: symptoms are confined to only one setting

• moderate: some symptoms are present in at least two settings

• severe: some symptoms are present in three or more settings

development and course for oppositional defiant disorder

first symptoms of ODD appear during preschool years and rare later than early adolescence. It often precedes the development of conduct disorder but it is possible for children and adolescents with ODD to not develop conduct disorder. behaviours associated with ODD increase in frequency during the preschool period and in adolescence.

differential diagnosis for oppositional defiant disorder

conduct disorder, adjustment disorder, PTSD, ADHD, depressive and bipolar disorders, disruptive mood dysregulation disorder, intermittent explosive disorder, intellectual developmental disorder, language disorder, social anxiety disorder

differential diagnosis for ODD: conduct disorder

the behaviours of ODD are typically less of a severe nature than those of conduct disorder and do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. however, ODD is associated with equivalent or even greater levels of impairment than conduct disorder. furthermore, ODD includes problems of emotional dysregulation that are not included in the definition of conduct disorder

reactive attachment disorder

A. A consistent pattern of inhibited, emotionally withdrawn behaviour 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 (e.g. frequent changes in foster care)

3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g institutions with high child-to-caregiver ratios)

D. The disturbances in Criterion A began following the lack of adequate care in Criterion C

E. The criteria are not met for ASD

F. The disturbance is evident before age of 5

G. The child has a development age of at least 9 months

Specify if:

• Persistent: disorder has been present for more than 12 months

Specify current severity:

• specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels

Development and course: conditions of social neglect are often present in the first months of life. The clinical features of the disorder manifest in similar fashion between the ages of 9 months and 5 years → absent-to-minimal attachment behaviours are evident but how these are expressed depends on differing cognitive and motor abilities.

differential diagnosis for reactive attachment disorder

ASD, intellectual development disorder, depressive disorders

differential diagnosis for reactive attachment disorder: ASD

young children with either condition can manifest dampened expression of positive emotions, cognitive and language delays, and impairments in social reciprocity. the two disorders can be distinguished based on differential histories of neglect and on the presence of restricted interests or ritualized behaviours, specific deficit in social communication, and selective attachment behaviours.

differential diagnosis for reactive attachment disorder: intellectual developmental disorder

developmental delays often accompany reactive attachment disorder as well. children with intellectual developmental disorder should exhibit social and emotional skills comparable to their cognitive skills and do not demonstrate the profound reduction in positive affect and emotional regulation difficulties evident in children with reactive attachment disorder. in addition, developmentally delayed children who reach a cognitive age 7-9 months should demonstrate selective attachments regardless of their chronological age. in contrast, children with reactive attachment disorder show lack of preferred attachment despite attaining developmental age of at least 9 months

disinhibited social engagement disorder

A. A pattern of behaviour 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 or interacting with unfamiliar adults

2. Overly familiar verbal or physical behaviours

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

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

B. The behaviours in Criterion A are not limited to impulsivity (as in ADHD) but include socially disinhibited behaviour

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 (e.g. frequent changes in foster care)

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 behaviour in Criterion A

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

Specify if:

• persistent: the disorder has been present for more than 12 months

Specify current severity:

• specified as severe when the child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels

Development and course: conditions of social neglect are often present in the first months of life. signs of the disorder have been described from the second year of life through adolescence and even into young adulthood.

differential diagnosis for disinhibited social engagement disorder

• ADHD: children with disinhibited social engagement disorder can be differentiated from those with ADHD accompanied by social impulsivity, as the former do not show difficulties with attention of hyperactivity

cluster A personality disorders

paranoid, schizoid, and schizotypal

individuals with these disorders often appear odd or eccentric.

median prevalence: 3.6%

cluster B personality disorders

antisocial, borderline, histrionic, and narcissistic

individuals with these disorders often appear dramatic, emotional, or erratic

median prevalence: 4.5%

cluster C personality disorders

avoidant, dependent, and obsessive-compulsive

individuals with these disorders often appear anxious or fearful

median prevalence: 2.8%

general personality disorder

applies to all 10 personality disorders

A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. The pattern is manifested in two or more of the following areas:

1. cognition (i.e. ways of perceiving and interpreting self, other people, and events)

2. affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response)

3. interpersonal functioning

4. impulse control

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations

C. The enduring patterns leads to significant distress or functional impairment

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 by another mental disorder

F. Not attributable to the effects of a substance or another medical condition

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. is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates

2. is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them

3. reads hidden demeaning or threatening into benign remarks or events

4. persistently bears grudges

5. perceives attacks of their character or reputation that are not apparent to others and is quick to react angrily or to counterattack

6. 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 a medical condition

Note: if criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e., '‘paranoid personality disorder (premorbid)”

Development and course: first apparent in childhood and adolescence with solitariness, social anxiety, underachievement in school. adolescent onset is associated with childhood maltreatment, bullying, externalizing symptoms.

differential diagnosis for paranoid PD

• other mental disorders with psychotic symptoms: for an additional diagnosis of paranoid PD to be given, the OD must have been present before the onset of psychotic symptoms and must persistent when psychotic symptoms are in remission

• other personality disorders

• medical conditions and substance use

• paranoid traits associated with physical handicaps

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 ASD and is not attributable to the effects of a medical condition

differential diagnosis for schizoid personality disorder

• ASD: particularly with mild forms of other disorder then can be hard to differentiate, as both include a seeming indifference to companionship with others. however, ASD may be differentiated by stereotyped behaviours and interests

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 behaviour, 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 behaviour 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. behaviour or appearance that is odd, eccentric, peculiar

8. lack of close friends or confidants other than first-degree relatives

9. 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, anther psychotic disorder, or ASD

differential diagnosis for schizotypal personality disorder

• neurodevelopmental disorders: communication disorders may be differentiated by the primacy and severity of the disorder in language and by the characteristic features of impaired language found in a specialized language assessment. Milder forms of ASD are differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped behaviours and interests

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 3 (more) of the following;

1. failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts that are grounds for arrest

2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

3. impulsivity or failure to plan ahead

4. irritability and aggressiveness, as indicated by repeated physical fights or assaults

5. reckless disregard for safety of self or others

6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honor financial obligations

7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another person

B. individual is at least age 18 years

C. evidence of conduct disorder with onset before age 15 years

D. the occurrence of antisocial behaviour is not exclusively during the course of schizophrenia or bipolar disorder

Development and course: has a chronic course but may become less evident or remit as the individual grows older, often by age 40. although this remission tends to be particularly evident with respect to engaging in criminal behaviour, there is likely to be a decrease in full spectrum of antisocial behaviours and substance use. 3x more common in men than in women.

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 5 (or more) of the following:

1. frantic efforts to avoid real or imagined abandonment

2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. identity disturbance: markedly and persistently unstable self-image or sense of self

4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)

5. recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

6. 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)

7. chronic feelings of emptiness

8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. transient, stress-related paranoid ideation or severe dissociative symptoms

Development and course: borderline PD has typically been thought of as adult onset, but found as early as age 12-13 years. more common in women than men in clinical settings, in community samples there is no difference.