DSM summarized

Neurodevelopmental Disorders

  • IDD (Intellectual Developmental Disorder): All 3 criteria must be met:
    • Deficits in intellectual functions.
    • Deficits in adaptive functioning.
    • Onset during the developmental period.
  • GDD (Global Developmental Delay): Used for children under 5 years old when the severity of intellectual disability cannot be reliably assessed.
  • Unspecified ID: Used for individuals above 5 years old when assessment is difficult.
  • Language Disorder:
    • Deficits in the development and use of language across modalities.
    • Difficulties in vocabulary, sentence structure, and discourse.
    • Can co-occur with Speech Sound Disorder (SSD).
  • SSD (Speech Sound Disorder):
    • Deficits in the development and use of speech.
    • Difficulties in speech sound production.
    • Examples include verbal dyspraxia and lisping.
    • Typically respond well to treatment.
  • Stuttering:
    • Disturbances in the normal fluency and motor production of speech.
    • Varies in severity from situation to situation.
    • May be absent during oral reading or singing.
    • Often involves fearful anticipation of speaking.
  • Social Pragmatic Communication Disorder:
    • Deficits in the development and use of social communication.
    • Includes difficulties in using communication for social purposes, changing communication to match context, and following rules of conversation.
    • Rare before the age of 4.
  • ASD (Autism Spectrum Disorder):
    • Characterized by deficits in social communication and interaction, and restricted, repetitive patterns of behavior, interests, or activities.
    • Severity is specified based on the level of support needed for social communication and restricted, repetitive behaviors.
    • May be accompanied by intellectual impairment, language impairment, or catatonia.
  • ADHD (Attention-Deficit/Hyperactivity Disorder):
    • Requires 6 or more symptoms of inattention or hyperactivity-impulsivity.
    • Presentation can be combined, predominantly inattentive, or predominantly hyperactive-impulsive.
  • SLD (Specific Learning Disorder):
    • Difficulties in learning and using academic skills.
    • Unexpected underachievement in one or more academic areas.
    • Manifests during formal schooling years.
    • Includes dyslexia (reading), dyscalculia (mathematics), and dysgraphia (writing).
  • DCD (Developmental Coordination Disorder):
    • Characterized by uncoordinated motor skills.
    • Diagnosis not given below 5 years of age.
    • Slowness or inaccuracy of performance of motor skills.
  • SMD (Stereotypic Movement Disorder):
    • Repetitive, driven, and seemingly purposeless motor behavior.
    • May cause self-injury.
  • Tic Disorders:
    • Involve sudden, recurrent, non-rhythmic, stereotyped motor movements or vocalizations (tics).
    • Tourette's Disorder: Both motor and vocal tics are present.
    • Persistent (Chronic) Motor or Vocal Tic Disorder: Either motor or vocal tics are present, but not both.
    • Provisional Tic Disorder: Motor and/or vocal tics have been present for less than one year.
  • Stereotypies vs. Tics vs. Chorea:
    • Stereotypies: More fixed, rhythmic, and prolonged.
    • Tics: Brief, rapid, random, and fluctuating.
    • Chorea: Rapid, random, continual, abrupt, irregular, unpredictable, non-stereotyped actions affecting all body parts bilaterally.
  • Motor Stereotypies: Involuntary rhythmic, repetitive, predictable movements that appear purposeful but serve no obvious adaptive function and stop with distraction.
  • Dystonia: Simultaneous sustained contraction of agonist and antagonist muscles, resulting in distorted posture or movement.

Schizophrenia Spectrum and Other Psychotic Disorders

  • Delusional Disorder:
    • Presence of one or more delusions.
    • Criterion A for schizophrenia (hallucinations, delusions, disorganized speech, etc.) has not been met.
    • No other psychotic symptoms.
  • Brief Psychotic Disorder:
    • Presence of one or more of the following: delusions, hallucinations, disorganized speech.
    • Rapid shift from one intense affect to another.
  • Schizophreniform Disorder:
    • Two or more of the symptoms of schizophrenia (hallucinations, delusions, disorganized speech, negative symptoms).
    • Duration is less than 6 months.
    • Depressive or manic episodes may occur, but are brief.
    • Similar development to schizophrenia.
  • Schizophrenia:
    • Two or more of the symptoms of schizophrenia (hallucinations, delusions, disorganized speech, negative symptoms).
    • Continuous signs of the disturbance persist for at least 6 months.
    • Depressive or manic episodes may occur, but are brief.
    • Can be associated with hostility and aggression.
  • Schizoaffective Disorder:
    • A mood episode (major depressive or manic) and the active phase symptoms of schizophrenia occur together.
    • At least 2 weeks of delusions or hallucinations without prominent mood symptoms.

Bipolar and Related Disorders

  • Bipolar I Disorder:
    • Presence of a manic episode.
    • Three or more symptoms during a manic episode (4 if irritable mood only).
    • Can be comorbid with anxiety disorders.
    • Diagnosis of personality disorder should not be made during an untreated mood episode.
  • Bipolar II Disorder:
    • Presence or history of hypomanic episode and major depressive episode (MDE).
    • MDE: Five or more symptoms present during the same 2-week period (depressed mood or anhedonia).
    • The usual complaint is more related to the MDE than hypomania.
  • Cyclothymic Disorder:
    • For at least 2 years (1 year in children and adolescents), there have been numerous periods with hypomanic symptoms and depressive symptoms that do not meet the criteria for a hypomanic episode or a major depressive episode.
    • Symptoms present for at least half the time, and individual has not been without symptoms for more than 2 months at a time.

Depressive Disorders

  • DMDD (Disruptive Mood Dysregulation Disorder):
    • Severe, recurrent temper outbursts inconsistent with developmental level.
    • Onset must be before 10 years old.
    • Outbursts occur, on average, three or more times per week.
    • Irritable or angry mood is present between outbursts.
    • Present for 12 or more months.
    • Irritable and angry mood + severe temper outbursts in at least 2 of 3 settings (home, school, peers).
    • Diagnosis cannot be made before age 6 or after age 18.
    • Cannot coexist with ODD, IED, or bipolar disorder.
    • If mood dysregulation present: diagnose DMDD, not ODD.
    • If criteria for both DMDD and ODD are met, diagnose with DMDD only.
    • Can be comorbid with ADHD or anxiety disorders.
    • IED: Active symptoms for 3 months; DMDD: active symptoms for 12 months.
  • MDD (Major Depressive Disorder):
    • Five or more symptoms present during the same 2-week period (depressed mood or anhedonia).
    • In grief, feelings of emptiness and loss are prominent.
    • Criterion symptoms must be present nearly every day.
    • In children/adolescents, irritable mood may be more common than sad mood.
    • Hyperactive HPA axis.
    • ADHD and MDD can be comorbid.
    • Full criteria for MDE not met in Adjustment Disorder.
  • PDD (Persistent Depressive Disorder) / Dysthymia:
    • Depressed mood for most of the day, for more days than not, for at least 2 years (1 year in children and adolescents).
    • Two or more additional symptoms.
    • Early onset associated with higher likelihood of comorbid personality disorders and substance abuse.
    • Double depression = PDD + MDD.
    • May have symptoms for more than 2 months.
    • Dysthymic syndrome: Criteria for MDD not met in the previous 2-year period.
    • Persistent MDD: Criteria for MDD met throughout the previous 2-year period.
    • Intermittent MDE without current episode: Full criteria for MDD has NOT been met, but an episode occurred in the previous 2-year period.
    • Severity specifiers: Mild (2 symptoms), Moderate (3 symptoms), Severe (4-5 symptoms and with motor agitation).
  • Premenstrual Dysphoric Disorder (PMDD):
    • Five symptoms must be present in the week before menses, improving within a few days after the onset of menses, and minimal or absent in the week postmenses.
    • Symptoms must not be merely an exacerbation of symptoms of another disorder.
    • Includes mood lability, irritability, dysphoria, and anxiety symptoms.
    • Symptom-free period in the follicular phase after the menstrual period begins.
    • PMS: Does not require a minimum of 5 symptoms; less severe.
    • Dysmenorrhea: Occurs during menses.
    • If symptoms are solely due to hormonal treatments, diagnose Substance/Medication-Induced Depressive Disorder.

Anxiety Disorders

  • Separation Anxiety Disorder:
    • Excessive fear or anxiety concerning separation from home or attachment figures.
    • Clinging behavior.
    • Most prevalent anxiety disorder in children younger than 12 years old.
    • 3 of the following symptoms are required:
      • Fear
      • Anxiety
      • Avoidance
    • Duration: Children (4 weeks), Adults (6 months or more).
    • Not all separation anxiety is abnormal, as it can be part of secure attachment development.
  • Selective Mutism:
    • Consistent failure to speak in specific social situations in which there is an expectation for speaking.
    • Children do not initiate speech or reciprocally respond when spoken to by others.
    • Speak at home with immediate family and have normal language skills.
    • Onset usually before age 5.
    • Sometimes use non-spoken or non-verbal means of communication.
    • Almost always accompanied by Social Anxiety Disorder (Social Phobia).
    • Some children outgrow it.
  • Specific Phobia:
    • Marked fear or anxiety about a specific object or situation.
    • Cued panic attacks.
    • Atypical: Blood-injury-injection (vasovagal fainting).
    • Need to specify the feared object or situation.
  • Social Anxiety Disorder (Social Phobia):
    • Fear of scrutiny or negative evaluation by others.
    • In children, may occur only in peer settings.
    • Social situations almost always provoke fear.
    • Self-medication with substances is common.
    • Specify if performance-only (fear is restricted to speaking or performing in public, e.g., stage fright).
  • Panic Disorder:
    • Recurrent unexpected panic attacks.
    • 4 or more symptoms that peak within minutes.
    • Can occur from a calm or anxious state.
    • Culture-specific symptoms may be seen.
    • Onset mostly in adolescence to young adulthood.
    • Nocturnal Panic: Panic attacks during delta or slow-wave sleep.
  • Panic Attack Specifier:
    • Misfire of the fear system.
    • May involve depersonalization/derealization.
    • 4 or more of the 13 symptoms (11 physical, 2 cognitive).
    • Culture-bound syndromes: Khyal, ataque de nervios, trung gio.
  • Agoraphobia:
    • Anxiety about 2 or more situations:
      • Public transportation
      • Open spaces
      • Enclosed spaces
      • Standing in line or being in a crowd
      • Outside of home alone.
    • Fear of not being able to escape or find help.
    • Need for a companion; homebound behavior.
    • Onset in childhood is rare.
    • Panic Disorder and Agoraphobia can be comorbid.
  • Generalized Anxiety Disorder (GAD):
    • Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.
    • 3 or more of the 6 symptoms (restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance).
    • Can have panic attacks.
    • Different sources of worry.

Obsessive-Compulsive and Related Disorders

  • OCD (Obsessive-Compulsive Disorder):
    • Presence of obsessions (recurrent, persistent thoughts, urges, or images that are experienced as intrusive and unwanted) and/or compulsions (repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession).
    • Obsessions and compulsions are time-consuming (more than 1 hour a day) and cause clinically significant distress or impairment.
    • Ego-dystonic; no rewarding effects.
    • Common obsessions: Cleaning, symmetry, taboo or forbidden thoughts, harm.
    • Compulsions are easier to diagnose in children.
    • Earlier onset in males and higher chance of comorbid tics.
      • Good/Fair insight: May be true or not true.
      • Poor Insight: Probably true.
      • Absent Insight: Convinced that it is true.
  • BDD (Body Dysmorphic Disorder):
    • Preoccupation with perceived defects or flaws in physical appearance, which are not observable or appear slight to others (but not weight-related).
    • May have repetitive behaviors (due to appearance concerns), such as excessive grooming or camouflaging.
    • Muscle dysmorphia (males).
    • May develop MDD and anxiety disorders.
  • Hoarding Disorder:
    • Persistent difficulty discarding or parting with possessions, regardless of their actual value.
    • Noah syndrome: Animal hoarding.
    • Clutter in the active living areas.
    • Begins early in life and spans well into later stages.
    • Women tend to excessively buy things.
  • Trichotillomania (Hair-Pulling Disorder):
    • Recurrent pulling out of one's hair, resulting in noticeable hair loss.
    • Not triggered by obsessions or preoccupations.
    • May be due to anxiety, boredom, tension.
    • May feel gratification after pulling hair.
    • Occurs with immediate family.
  • Excoriation (Skin-Picking) Disorder:
    • Recurrent skin picking, resulting in skin lesions.
    • Not triggered by obsessions or preoccupations.
    • May be due to anxiety, boredom, tension.
    • May feel gratification after.
    • Occurs with immediate family.
    • Pain is routinely not reported.
    • Some use nails or tweezers.

Trauma- and Stressor-Related Disorders

  • Reactive Attachment Disorder:
    • A pattern of disturbed and developmentally inappropriate attachment behavior, evident before age 5, in which a child rarely seeks comfort or responds when distressed.
    • Due to:
      • Social neglect or deprivation of needs.
      • Repeated changes in primary caregivers.
      • Rearing in unusual settings that limit the opportunity to form selective attachments.
    • Features:
      • Minimal social and emotional response.
      • Limited positive affect.
      • Episodes of unexplained irritability, sadness, or fearfulness.
    • Did not meet criteria for ASD.
    • Persistent: Present for more than 12 months.
  • Disinhibited Social Engagement Disorder:
    • A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
      • Reduced reticence in approaching or interacting with unfamiliar adults.
      • Overly familiar behavior, violating social and cultural boundaries.
      • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
      • Willingness to go off with an unfamiliar adult with minimal or no hesitation.
    • No stranger anxiety; overly familiar with strangers.
    • Developmental age of at least 9 months.
    • Persistent: Present for more than 12 months.
  • PTSD (Posttraumatic Stress Disorder):
    • Exposure to actual or threatened death, serious injury, or sexual violence.
    • Direct experience, witnessing in person, learning that it occurred to a close family member or friend, or experiencing repeated or extreme exposure to aversive details of traumatic events.
    • Symptoms last for more than 1 month.
    • One or more intrusive symptoms:
      • Memories
      • Dreams
      • Dissociative reactions
      • Distress
      • Physiological reactions.
    • Avoidance of stimuli associated with the traumatic event:
      • Avoidance of memories, thoughts, or feelings.
      • Avoidance of external reminders.
    • Negative alterations in cognitions and mood:
      • Inability to remember aspects of the trauma.
      • Exaggerated negative beliefs.
      • Cognitive distortions.
      • Negative mood states.
    • Marked alterations in arousal and reactivity:
      • Irritable behavior and angry outbursts.
      • Reckless or self-destructive behavior.
      • Hypervigilance.
      • Exaggerated startle response.
      • Concentration problems.
      • Sleep disturbance.
    • Possible delayed expression (full criteria met until at least 6 months after the event).
  • Acute Stress Disorder:
    • Similar to PTSD, but symptoms last for 3 days to 1 month after the trauma.
    • Can have a stronger anger response.
    • Typically involves anxiety response.
    • 9 or more symptoms from the 5 categories (intrusion, negative mood, dissociation, avoidance, arousal).
  • Adjustment Disorder:
    • Emotional or behavioral symptoms in response to an identifiable stressor(s), occurring within 3 months of the onset of the stressor(s).
    • Stressor may be single or multiple, and may be recurrent or continuous.
    • Onset is usually immediate.
    • May progress to PTSD.
    • Symptoms do not persist for an additional 6 months after the stressor has terminated.
    • Symptoms do not represent normal bereavement.

Dissociative Disorders

  • Involve unbidden intrusions into awareness and behavior and/or inability to access information or control mental functions.
  • Dissociative Identity Disorder (DID):
    • Presence of two or more distinct personality states or an experience of possession.
    • Recurrent episodes of amnesia.
    • Gaps in memory of personal events.
    • Lapses in dependable memory.
    • Acts that they have no memory of.
    • Children: Must not be better explained by imaginary playmates or other fantasy play.
    • Dissociative fugues, flashbacks.
    • High degrees of hypnotizability and dissociativity.
    • Can co-occur with PTSD.
    • Rarely diagnosed in childhood; usually in adulthood.
  • Dissociative Amnesia:
    • Inability to recall autobiographical memory only (inconsistent with normal forgetting).
    • Types:
      • Localized (event or period of time).
      • Selective (aspect).
      • Generalized (identity and life history).
      • Systematized (category).
      • Continuous (as it occurs).
    • Can’t form or sustain satisfactory relationships.
    • Dissociative fugue: Purposeful travel.
    • Rule out: TBI, Dementia, Substance Abuse.
    • Amnesias are relatively stable.
    • Can be comorbid with PTSD.
    • Non-purposeful wandering may be associated with seizures.
  • Depersonalization/Derealization Disorder:
    • Intact reality testing.
    • Depersonalization: Feelings of unreality, detachment from self; can experience split self.
    • Derealization: Feelings of unreality, detachment from environment; subjective visual distortions; voices/sounds are muted or heightened.
    • Dysregulation in HPA axis; reduced emotional responding.
    • Dissociative Trance: (Asian and Non-Western); Ex: Sapi.

Somatic Symptom and Related Disorders

  • Somatic Symptom Disorder (SSD):
    • Previously Briquet's Syndrome; somatic presentations are idioms of distress.
    • 75% of those diagnosed with hypochondriasis are now diagnosed with SSD.
    • Symptoms can be specific or non-specific.
    • Severe cases can lead to invalidism (severe disability).
    • High level of medical care utilization.
    • Prominent in culture-bound syndromes.
    • Criterion A: One or more somatic symptoms that are distressing or result in significant disruption of daily life.
    • Criterion B: Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
      • Disproportionate and persistent thoughts about the seriousness of one's symptoms.
      • High level of anxiety about health or symptoms.
      • Excessive time and energy devoted to these symptoms or health concerns.
    • Mild: 1 symptom in Criterion B. Moderate: 2 or more in Criterion B. Severe: 2 or more in Criterion B + multiple somatic symptoms.
    • If both SSD and criteria for another mental disorder are met, both are coded.
  • Illness Anxiety Disorder:
    • Preoccupation with having or acquiring a serious illness.
    • Little to no somatic symptoms.
    • Primary distress is with the idea of being sick; excessive worry; always seeks multiple doctors; extensive health-related research.
    • In older people, memory loss is the usual concern.
    • Almost any physical sensation may become the basis for concern.
    • Can be care-seeking or care-avoidant.
  • Conversion Disorder (Functional Neurological Symptom Disorder):
    • Medically unexplainable symptoms affecting motor or sensory function.
    • May have one or more symptoms of various types (motor, sensory, or other symptoms).
    • Diagnosis should be based on the overall clinical picture.
    • May have:
      • History of trauma.
      • Dissociative symptoms like derealization, depersonalization, and dissociative amnesia.
    • La belle indifference (lack of concern about symptoms) should not be used to make a diagnosis.
    • Children have a better chance of recovering.
    • Acute: Less than 6 months. Persistent: More than 6 months.
  • Factitious Disorder:
    • Falsification of medical or psychological signs and symptoms in oneself or others.
    • Involves deception, including fabrication, exaggeration, simulation, or induction.
    • Can have a pre-existing medical condition but still deceives.
    • Deceives even in the absence of obvious external rewards (just assuming sick role); if with obvious rewards, it is considered malingering.
    • Factitious Disorder Imposed on Another / Munchausen Syndrome by Proxy / Imposed on Another (perpetrator receives the diagnosis).

Feeding and Eating Disorders

  • Pica Disorder:
    • Persistent eating of non-nutritive, non-food substances over a period of at least one month.
    • Minimum age for diagnosis is 2 years old.
    • Can be an associated feature of other mental disorders.
    • Tend to increase in prevalence among those with severe intellectual disabilities.
    • May occur in both genders, including during pregnancy.
  • Rumination Disorder:
    • Repeated regurgitation of food over a period of at least one month. Regurgitated food may be re-chewed, re-swallowed, or spit out.
    • May be diagnosed across the lifespan, especially in those with intellectual disabilities.
    • May be habitual or out of their control.
    • Regurgitation is not associated with GI or other medical conditions.
  • Avoidant/Restrictive Food Intake Disorder (ARFID):
    • Disturbance in eating or feeding, resulting in persistent failure to meet appropriate nutritional and/or energy needs.
    • Avoidance may be based on sensory characteristics of the food.
    • More common among children.
    • One or more of the following:
      • Significant weight loss.
      • Nutritional deficiency.
      • Dependence on enteral or oral nutritional supplements.
      • Marked interference with psychosocial functioning.
    • Common in both genders, but with ASD, affects mostly males.
  • Anorexia Nervosa (AN):
    • Persistent energy intake restriction, intense fear of gaining weight or of becoming fat, disturbance in perceived weight or shape.
    • BMI is lower than 18.5.
    • Affects most major organ systems.
    • May have lanugo (fine, downy hair).
    • OC features are prominent.
    • Onset is associated with stressful life events.
    • Can be:
      • Restricting type.
      • Binge-eating/purging type.
    • Severity based on BMI:
      • Mild: > 17 kg/m^2
      • Moderate: 16−16.99kg/m216-16.99 kg/m^2
      • Severe: 15−15.99kg/m215-15.99 kg/m^2
      • Extreme: < 15 kg/m^2
    • Low WBC, bone mineral density, resting energy expenditure, mild anemia, sinus bradycardia, rare arrhythmias, electrolyte imbalance.
    • Amenorrhea, delayed menarche, emaciation, hypotension, hypothermia.
    • Dental enamel erosion, callouses on knuckles (Russell's sign), yellowing of the skin.
  • Bulimia Nervosa (BN):
    • Recurrent episodes of binge eating. An episode of binge eating is characterized by both:
      • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
      • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
    • Binge eating need not be restricted to one setting.
    • Binges typically occur in secret.
    • May feel ashamed/guilty and conceal their symptoms.
    • Individuals usually eat foods they would avoid.
    • Most are overweight or obese.
    • Severity based on episodes of inappropriate compensatory behaviors (ICB) per week:
      • Mild: 1-3 episodes.
      • Moderate: 4-7 episodes.
      • Severe: 8-13 episodes.
      • Extreme: 14 or more episodes.
    • Hypokalemia, electrolyte imbalance, diarrhea, dental enamel erosion, dental caries, enlarged salivary glands.
  • Binge-Eating Disorder (BED):
    • Recurrent episodes of binge eating in the absence of regular use of inappropriate compensatory behaviors to control weight.
    • An episode of binge eating is characterized by both:
      • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
      • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
    • Three or more of the following:
      • Eating much more rapidly than usual.
      • Eating until feeling uncomfortably full.
      • Eating large amounts of food when not feeling physically hungry.
      • Eating alone because of feeling embarrassed by how much one is eating.
      • Feeling disgusted with oneself, depressed, or very guilty afterward.
    • Severity based on binge episodes per week:
      • Mild: 1-3 binges per week.
      • Moderate: 4-7 binges per week.
      • Severe: 8-13 binges per week.
      • Extreme: 14 or more per week.
    • More of a generalized pattern of uncontrolled eating.
    • May feel ashamed/guilty and conceal their symptoms.
    • Individuals usually eat foods they would avoid.
    • Overweight or obese; negative self-evaluation and dysphoria.
    • Crossover from binge eating to other Eating Disorders is uncommon.
  • Other Specified Feeding or Eating Disorder:
    • Atypical AN (weight is within normal range).
    • BN of limited duration (full criteria not met, less than 3 months).
    • Purging disorder (purge without binge eating).
    • Night eating syndrome (with recall).

Elimination Disorders

  • Enuresis (Urine):
    • Repeated voiding of urine into bed or clothes (involuntary or intentional).
    • During REM sleep.
    • Commonly occurs in the early afternoon on school days and can be associated with symptoms of disruptive behavior.
    • Higher prevalence among 5-year-olds.
    • Types:
      • Primary: Has never established urinary continence; age 5 y/o
      • Secondary: Develops after a period of established urinary continence; age 5-8 y/o
    • Nocturnal (nighttime sleep), diurnal (waking hours), or a combination of both.
  • Encopresis (Feces):
    • Repeated passage of feces into inappropriate places (involuntary or intentional).
    • Chronological age of 4.
    • Inconsistent toilet training and psychosocial stress may be predisposing factors.
    • Can be with constipation and overflow incontinence or without constipation and overflow incontinence.
    • Types:
      • Primary: Has never established fecal continence.
      • Secondary: Develops after a period of established fecal continence.

Sleep-Wake Disorders

  • Dyssomnias: Disorders of sleep quantity, quality, and timing.
    • Insomnia Disorder:
      • Can be an independent or comorbid disorder; can be a risk factor for depression; non-restorative sleep.
      • Types of insomnia:
        • Sleep Onset: Difficulty falling asleep at bedtime.
        • Sleep Maintenance: Waking up during the night and having difficulty returning to sleep.
        • Late/Terminal Insomnia: Waking up too early and being unable to fall back asleep.
      • Daytime sleepiness (especially among elders and when insomnia is a comorbid disorder).
      • Subjective report of difficulty with sleep initiation, duration, consolidation, or quality.
      • At least 3 nights per week for at least 3 months.
      • Specify:
        • Episodic: 1 month - < 3 months.
        • Persistent: 3 months or longer.
        • Recurrent: Two or more episodes within 1 year.
      • Activation of HPA Axis.
    • Hypersomnolence Disorder:
      • Excessive sleepiness despite getting at least 7 hours of sleep.
      • Have difficulty waking up in the morning, appearing confused, combative, or ataxic.
      • Experience sleep inertia (prolonged impairment of alertness at the sleep-wake transition).
      • One of the following:
        • Recurrent periods of sleep or lapses into sleep within the same day.
        • Prolonged main sleep episode of more than 9 hours per day that is non-restorative.
        • Difficulty being fully awake after abrupt awakening.
      • At least 3x per week for at least 3 months.
      • Specify:
        • Acute: < 1 month.
        • Subacute: 1-3 months.
        • Persistent: > 3 months.
      • Severity:
        • Mild: Difficulty in maintaining daytime alertness 1-2 days/week.
        • Moderate: Difficulty in maintaining daytime alertness 3-4 days/week.
        • Severe: Difficulty in maintaining daytime alertness 5-7 days/week.
    • Narcolepsy:
      • Irresistible attacks of refreshing sleep, cataplexy, or both.
      • Some experience hypnagogic (before falling asleep) or hypnopompic (upon awakening) hallucinations.
      • 3x a week for 3 mos.
      • One of the following:
        • Episodes of cataplexy (bilateral loss of muscle tone; in children, spontaneous grimaces or jaw opening with tongue thrusting or global hypotonia). Hypocretin deficiency.
        • Nocturnal sleep polysomnography showing REM sleep latency < or == to 15 minutes or multiple sleep latency latency < or == to 8 minutes and two or more sleep onset REM periods.
      • Associated with obesity and premature puberty; symptom manifestation decreases with age or treatment.
    • Breathing-Related Sleep Disorders:
      • Obstructive Sleep Apnea Hypopnea:
        • Polysomnography results in at least 5 obstructive apneas or hypopneas per hour of sleep.
        • Either of the following:
          • Nocturnal breathing disturbances (e.g., snoring, gasping, pauses in breathing during sleep).
          • Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities for sleep.
        • May report symptoms of insomnia; associated with obesity.
      • Central Sleep Apnea:
        • Evidence by polysomnography of 5 or more central apneas per hour of sleep.
        • Idiopathic CSA: No evidence of airway obstruction.
        • Cheyne-Stokes Breathing: Crescendo-decrescendo pattern of respiration and/or related apneas.
      • Sleep Related Hypoventilation:
        • Decreased respiration associated with elevated CO2CO_2 levels.
        • Those affected may report excessive daytime sleepiness, frequent arousal and awakenings during sleep, morning headaches, and insomnia complaints.
    • Circadian Rhythm Sleep-Wake Disorders:
      • Disruption in the circadian rhythm leading to insomnia or excessive sleepiness.
      • Types:
        • Delayed Sleep Phase Type (can't sleep at usual time).
        • Advanced Sleep Phase Type (earlier sleep and wake times than desired).
        • Irregular Sleep-Wake Type (symptoms of insomnia at night and excessive sleepiness during daytime; no major sleep-wake period; fragmented sleep).
        • Non-24-Hour Sleep-Wake Type (abnormal synchronization between the 24-hour light-dark cycle and the endogenous circadian rhythm).
        • Shift Work Type (working outside of normal hours).
  • Parasomnias: Abnormal events occurring during sleep.
    • Non-REM Sleep Arousal Disorders:
      • Brief; 1-10 minutes; eyes are typically open.
      • Sleepwalking: Slow waves, first 1/3 of the night, reduced alertness and responsiveness, blank stare; can be related to eating or sexual behavior