DSM-V Overview for Addiction Counsellors

Introduction

• The DSM is used by psychologists, psychiatrists, and medical professionals to diagnose mental health disorders.
• DSM stands for the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.
• The DSM-V is the current version and has been translated into over twenty languages and is used across the world.

History of the DSM

• 1840: US census recorded the number of people with “idiocy and insanity”.
• 1880: Census reported seven categories of mental health:
  • Mania (elevated mood)
  • Melancholia (depression)
  • Monomania (obsessions)
  • Paresis (muscle weakness or paralysis due to brain injury)
  • Dementia
  • Dipsomania (alcoholism)
  • Epilepsy
• 1917: American Medico–Psychological Association and the National Commission on Mental Hygiene developed a plan to gather data about the number of people living with mental illness, but it did not explain how to diagnose mental disorders.
• 1921: American Medico–Psychological Association changed its name to the American Psychiatric Association (APA).
  • The APA developed a psychiatric classification system used in the first edition of the American Medical Association’s Standard “Statistical Manual for the Use of Institutions for the Insane”.
  • The manual included 22 diagnostic categories, mostly psychotic conditions, physical disabilities, and disease-related complications (e.g., Syphilis of the brain).
• After World War II, the U.S. Army developed a broader classification system due to soldiers showing physical, psychological, and personality symptoms.
• The World Health Organization (WHO) published the sixth edition of International Classification of Diseases (ICD), which included:
  • 10 categories for psychoses and psychoneuroses
  • 7 categories for disorders of personality, behaviour, and intelligence
• 1952: The APA developed a variant of the ICD–6, which was published as the first edition of DSM.
  • The DSM described various psychiatric illnesses and was the first official manual of mental disorders used to diagnose mental disorders.
  • The DMS-I included 102 broad categories divided into two major groups of mental disorders:
    • Conditions caused by brain damage
    • Conditions resulting from socio-environmental stressors – this group of disorders was divided into:
      • Psychoses - severe conditions such as manic-depressive disorder or schizophrenia
      • Psychoneuroses - conditions such as anxiety, depressive disorders, and personality
• The DSM-II listed 182 mental disorders.
• The development of the DSM–III was coordinated with the development of the ICD–9, which was published in 1975 and implemented in 1978.
• The DSM-III expanded on the definitions of mental disorders and included milder conditions seen in the general population.
  • The DSM–III listed 265 mental disorders.
  • It also introduced point-by-point diagnostic criteria, a multi-axial diagnosis system, and a neutral approach in terms of what causes mental disorders.
  • The ICD–9 did not include diagnostic criteria or a multi-axial system because its primary function is to outline categories for the collection of basic health statistics.
  • In contrast, DSM–III was developed with the additional goal of providing precise definitions of mental disorders for clinicians and researchers.
• By this time, psychological assessments, rating scales, and checklists for anxiety and depression had been introduced.
• Research into mental illness increased, and more therapy techniques were developed and put into practice.
• Psychiatric medications such as anti-depressants were common by the 1960s.
• Experience with DSM-III revealed inconsistencies where diagnostic criteria were not clear.
• The APA appointed a work group to revise DSM–III, which developed the revisions and corrections that led to the publication of DSM–III–R in 1987.
• The DSM–IV was published in 1994 and listed 294 disorders.
  • It was the culmination of a 6-year effort that involved more than 1,000 individuals and numerous professional organizations.
  • Much of the effort involved conducting a comprehensive review of the literature to establish a firm empirical basis for making modifications.
  • Numerous changes were made to the classification (disorders were added, deleted, and reorganized), and new diagnostic criteria were given.
  • Developers of DSM–IV and the 10th edition of the ICD worked closely to coordinate their efforts, resulting in a better alignment between the two systems.
  • The ICD–10 was published in 1992.
• Work groups were formed in 2000 to create the outline for the fifth revision of DSM (DSM–5).
  • These work groups generated hundreds of white papers, providing summaries of psychiatric diagnosis and identifying the gaps.
• In 2007, APA formed the DSM–5 Task Force to begin revising the manual, as well as 13 work groups focusing on various disorder areas.
• The DSM–V was published in 2013.

DSM Timeline

• DSM-I:
  • Year published: 1952
  • No. of diagnoses: 106
• DSM-II:
  • Year published: 1968
  • No. of diagnoses: 182
• DSM-III:
  • Year published: 1980
  • No. of diagnoses: 265
• DSM-IV:
  • Year published: 1994
  • No. of diagnoses: 297
• DSM-IV-TR:
  • Year published: 2000
  • No. of diagnoses: 365
• DSM-V:
  • Year published: 2013

Why Do We Need the DSM-V?

• The DSM is the ‘bible’ for psychologists and psychiatrists and it is used because:
  • There is a standardised set of disorders and criteria for diagnosis of each disorder, so when one clinician talks to another and refers to a diagnosis, all parties know what type of symptoms are being presented.
  • It prevents diagnoses being made randomly because it is based on scientific studies and research – a patient must present with a certain number and types of symptoms to be diagnosed with a disorder.
  • It helps to determine the type of therapy that should be used and what the likely treatment response will be (the prognosis for the patient).
  • It reflects the current thinking on societal and cultural issues (for example, homosexuality was defined as a psychological disorder in the 3rd edition of the DSM but it was removed in the 4th version because it is no longer viewed as being deviant or pathological)

DSM-V Organisation

• The DSM-V is organised into 3 sections, with 20 chapters that address specific disorders.
  • Section 1 – introduces the new organisation, revisions and reviews
  • Section 2 – includes the diagnostic criteria and codes for the mental disorders, based on ICD codes
  • Section 3 – introduces new assessment tools, highlights disorders for further research and the glossary of terms
• The DSM-V diagnostic criteria include subtypes and specifiers.
  • Subtypes define different presentations of a disorder (for example, a Bipolar Mood Disorder patient who is in a manic episode)
  • Specifiers are used to indicate severity (mild, moderate, severe).

DSM-V Classifications

• Neurodevelopmental disorders:
  • Intellectual Disabilities
  • Communication Disorders
  • Autism Spectrum Disorders
  • Attention-Deficit / Hyperactivity Disorder
  • Specific Learning Disorders
  • Motor Disorders
• Schizophrenia Spectrum and Other Psychotic Disorders:
  • Schizotypal Personality Disorder
  • Delusional Disorder
  • Brief Psychotic Disorder
  • Schizophreniform Disorder
  • Schizophrenia
  • Schizoaffective Disorder
  • Substance / Medication Induced Psychotic Disorder
• Bipolar and Related Disorders:
  • Bipolar I Disorder
  • Bipolar II Disorder
  • Cyclothymic Disorder
  • Substance / Medication Induced Bipolar and Related Disorders
• Depressive Disorders:
  • Disruptive Mood Dysregulation Disorder
  • Major Depressive Disorder
  • Dysthymia
  • Adjustment Disorders
  • Other Specified Trauma and Stressor Related Disorder
• Dissociative Disorders:
  • Dissociative Identity Disorder
  • Dissociative Amnesia
  • Depersonalisation / Derealisation Disorder
• Somatic Symptom and Related Disorders:
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
  • Factitious Disorder
• Feeding and Eating Disorders:
  • Pica
  • Rumination Disorder
  • Avoidant / Restrictive Food Intake Disorder
  • Anorexia Nervosa
  • Bulimia Nervosa
  • Binge-eating Disorder
• Elimination Disorders:
  • Enuresis (bed wetting)
  • Encopresis (soiling with feces)
• Sleep-Wake Disorders:
  • Insomnia Disorder
  • Narcolepsy
  • Breathing Related Sleep Disorders
  • Parasomnias (sleepwalking, nightmares, restless leg syndrome)
• Sexual Dysfunctions:
  • Delayed Ejaculation
  • Erectile Disorder
  • Female Orgasmic Disorder
  • Female Sexual Interest / Sexual Arousal Disorder
  • Genito-Pelvic Pain / Penetration Disorder
  • Male Hypoactive Sexual Desire Disorder
  • Premature Ejaculation
• Gender Dysphoria: (transgender)
• Disruptive, Impulse - Control and Conduct Disorders:
  • Oppositional Defiant Disorder
  • Intermittent Explosive Disorder
  • Conduct Disorder
  • Antisocial Personality Disorder
  • Pyromania
  • Kleptomania
• Substance-Related and Addictive Disorders
  • Alcohol- Related Disorders
  • Caffeine Related Disorders
  • Cannabis Related Disorders
  • Hallucinogenic-Related Disorders
  • Inhalant-Related Disorders
  • Opioid-Related Disorders
  • Sedative, Hypnotic or Anxiolytic-Related Disorders
  • Stimulant-Related Disorders
  • Tobacco-Related Disorders
  • Non-Substance-Related Disorders
  • Gambling Disorder
• Neurocognitive Disorders:
  • Delirium
  • Major and Mild Neurocognitive Disorders
  • Alzheimer's Disease
  • Frontotemporal Disorder
  • Lewy Bodies
  • Vascular Disorder
  • Traumatic Brain Injury
  • Substance/Medication Induced
  • HIV Infection
  • Prion Disease
  • Parkinson's Disease
  • Huntington's Disease
  • Multiple Etiologies
• Personality Disorders:
  • Cluster A:
    • Paranoid Personality Disorder
    • Schizoid Personality Disorder
    • Schizotypal Personality Disorder
  • Cluster B:
    • Antisocial Personality Disorder
    • Borderline Personality Disorder
    • Histrionic Personality Disorder
    • Narcissistic Personality Disorder
  • Cluster C:
    • Avoidant Personality Disorder
    • Dependent Personality Disorder
    • Obsessive-Compulsive Personality Disorder
• Paraphilic Disorders:
  • Voyeuristic Disorder
  • Exhibitionistic Disorder
  • Frotteuristic Disorder
  • Sexual Masochism Disorder
  • Sexual Sadism Disorder
  • Pedophilic Disorder
  • Fetishistic Disorder
  • Transvestic Disorder
• Medication-Induced Movement Disorders:
  • Neuroleptic-Induced Parkinsonism
  • Neuroleptic-Malignant Syndrome
  • Medication-Induced Acute Dystonia
  • Medication-Induced Acute Akathisia
  • Tardive Dyskinesia
  • Tardive Akathisia
  • Medication-Induced Postural Tremor
  • Antidepressant Discontinuation Syndrome
• Other Conditions That May Be a Focus of Clinical Attention:
  • Problems Related to Family Upbringing
  • Parent-Child Relational Problem
  • Sibling Relational Problem
  • Upbringing Away from Parents
  • Child Affected by Parental Relationship Distress
  • Problems Related to Primary Support Group
  • Relationship Distress with Spouse or Intimate Partner
  • Disruption of Family by Separation or Divorce
  • High Expressed Emotion Level with Family
  • Uncomplicated Bereavement
  • Abuse and Neglect
  • Child Physical Abuse
  • Child Sexual Abuse
  • Child Neglect
  • Child Psychological Abuse
  • Spouse or Partner Violence, Physical
  • Spouse or Partner Violence, Sexual
  • Spouse or Partner, Neglect
  • Spouse or Partner Abuse, Psychological
  • Adult Abuse by Non-spouse or Non-partner
  • Educational and Occupational Problems
  • Educational Problems
  • Occupational Problems
  • Housing and Economic Problems
  • Housing Problems
  • Economic Problems
  • Problems Related to the Social Environment
  • Problems Related to Crime or Interaction with the Legal System
  • Problems Related to Psychosocial, Personal and Environmental Circumstances
  • Religious or Spiritual Problems
  • Unwanted Pregnancy
  • Multiparity
  • Discord with Social Service Provider
  • Victim of Terrorism or Torture
  • Exposure to Disaster, War or Other Hostilities
  • Circumstances of Personal History
  • Psychological Trauma
  • Self-harming
  • Military Deployment
  • Lifestyle
  • Adult Antisocial Behaviour
  • Child and Adolescent Antisocial Behaviour
  • Problems Related to Access to Medical and Other Health Care
  • Nonadherence to Medical Treatment

Neurodevelopmental Disorders

• Neurodevelopmental disorders are a group of conditions which start during infancy and childhood.
• They are characterised by deficits or lack of acquisitions of skills related to developing personally, socially and academically.
• The disorders cover a range of deficits from learning problems, lack of impulse control or social skills and global impairment across a range of functions.
• Different types of neurodevelopmental disorders:
  • Intellectual disabilities:
    • General mental abilities such as reasoning, problem solving, planning, abstract thinking, judgement and learning are impaired.
    • Individuals have cognitive problems and can’t function independently.
    • Depending on severity, a person may not be able to look after their personal hygiene, might not be able to talk or go to school.
  • Communication disorders:
    • These include problems with language and speech, such as stuttering.
  • Autism spectrum disorders:
    • Individuals with these types of disorders find it very difficult to communicate and interact with others.
    • Their ability to understand non-verbal cues and the give and take of conversations.
    • They often show restricted, repetitive patterns of behaviour (for example, rocking or lining toys up according to colour).
  • Attention-Deficit / Hyperactivity Disorder:
    • Diagnosed when the child presents with difficulty paying attention and concentrating, has excess energy and is disorganised.
    • People with ADHD find it difficult to stay on task and listen to instructions.
    • They may be fidgety and have problems sitting still.
    • They interrupt other people and find waiting their turn difficult.
  • Motor disorders:
    • These include problems with coordination, stereotypical or repetitive movements (tic disorders), excessive clumsiness and slowness and difficulty with fine and gross motor skills.
  • Specific learning disorders:
    • These are diagnosed when a child has a problem with one specific area of learning, like reading or writing.
    • The disorder affects the child’s school performance and is not because the child was not able to attend school.

Intellectual Disabilities Diagnostic Criteria

• Onset during developmental period
• Problems in intellectual functioning
  • Reasoning
  • Problem solving
  • Planning
  • Abstract thinking
  • Judgment
  • Learning from experience
• Problems performing daily activities (adaptive functioning)
  • Not meeting developmental milestones (for example, not walking or speaking)
  • Difficulty living independently in home, school and work environments
  • Difficulty communicating with others
  • Problems looking after personal hygiene and self-care (not being able to bath or dress on their own)
• NB: An intellectual disability is only diagnosed when the patient’s IQ has been assessed using psychological tests AND there is evidence that they cannot look after themselves (this should be provided by someone who lives with the person).

Classification of Intellectual Disability According to Severity

• Mild:
  • May be able to live independently
  • May be able to work
  • Can learn to read, write and do maths up to a Grade 6 level
• Moderate:
  • May be able to read and write a little
  • Can work in sheltered employment
  • Will need supervision in their home environment
  • Can learn skills such as personal hygiene
• Severe:
  • Unlikely to be able to read or write
  • May be able to learn some skills and routines
  • Will require constant supervision
• Profound:
  • Requires constant supervision and intensive support
  • May be able to communicate but unlikly
  • May have other medical conditions that require ongoing care

Communication Disorders

• Diagnosed when there are problems with language, speech and communication.
  • Speech is the expressive production of sound and includes articulation and voice.
  • Language is the form, function and use of a set of symbols (like English).
  • Communication is any verbal or non-verbal behaviour
• This group of disorders includes:
  • Language Disorder – difficulty acquiring spoken and / or written language
  • Speech sound disorder – problems producing sounds
  • Childhood-onset fluency disorder (stuttering)
  • Social (pragmatic) communication disorder - difficulty with verbal and non-verbal communication in social settings
  • Autism spectrum disorder - problems with social communication

Attention-Deficit / Hyperactivity Disorder

• Persistent inattention and / or hyperactivity and impulsivity

Specific Learning Disorder

• Difficulty learning and using academic skills
  • Sub-categories:
    • Dyslexia - words
    • Dyscalculia - maths

Movement Disorders

• Developmental coordination disorder - Poor motor skills below what is expected for that age
• Stereotypical movement disorder - Repetitive, driven and purposeless motor behaviour (for example, hand shaking, body rocking, biting, head banging)
• Tic disorders - sudden, rapid, recurrent motor movement or sound

Schizophrenia Spectrum and Psychotic Disorders

• It is important to know the symptoms of schizophrenia spectrum and psychotic disorders in addiction related services because of the overlap between psychosis caused by biological or psychiatric issues or substance related psychosis.

Psychosis

• Psychosis is diagnosed when the following are present.

Positive Symptoms

• Delusions - a false and firmly held belief about reality that is not held by everyone else and which cannot be changed despite proof to the contrary.
  • Bizarre delusions - a belief in something that is not possible – for example, that world leaders are aliens
  • Non-bizarre - a belief in something that is possible – for example, being under police surveillance
  • Different Types of Delusions
    • Erotomanic delusions: Belief that a person is in love with you
    • Grandiose delusions: Belief that you are special, with an inflated sense of self-worth, knowledge, power or relationship with a diety or famous person
    • Referential delusions: Belief that everyday occurances are specifically related to you or are caused by you
    • Persecutory delusions: Belief that someone is "out to get you" or is using magic or gossip to harm you
    • Control delusions: Belief that you are being controlled by forces outside of you
    • Somatic delusions: Belief that you have a physical defect or illness
• Hallucinations – a sensory perception of something that is not there.
  • Different Types of Hallucinations:
    • Visual: Something you see. Example: snakes coming out of the ceiling
    • Auditory: Something you hear. Example: voices telling you to kill yourself
    • Tactile: Something you feel. Example: feeling that something is living in your stomach
    • Olfactory: Something you smell. Example: rotten meat or chemicals
• Disorganised thinking (cognitive changes such as difficulty concentrating) – this is normally picked up from the person’s speech.
  • The psychotic person may:
    • Move from one topic to another with no logical connection (derailment)
    • Talk about things that are not related to questions or topics (tangential)
    • Be incoherent
• Disorganised or abnormal motor functioning – this includes:
  • Odd body movements (getting stuck in one position)
  • Catatonia (not moving at all, mutism, general unresponsiveness)
  • Stereotypical behaviours (hand flapping, rocking, echoing, grimacing)

Negative Symptoms

• No motivation (apathy)
• Sitting for long periods of time doing nothing (avolition)
• No pleasure in activities that used to be enjoyable (anhedonia)
• Social withdrawal
• Diminished emotional expressions – no facial expressions, flat tone of speech and limited hand, face and body movements when talking

Psychotic Disorders

• Delusional Disorder:
  • Diagnosed using the following criteria:
    • The presence of delusions for more than 1 month (specify type – erotomanic, persecutory, etc)
    • No other psychotic features are present (e.g. hallucinations)
    • Functioning is not impaired beyond the delusional thinking
    • Not caused by substance use
• Brief Psychotic Disorder:
  • Diagnosed using the following criteria:
    • The presence of delusions, hallucinations, disorganised speech and disorganised behaviour
    • The episode has lasted more than a day but less than a month
    • The episode is not caused by another disorder such as depression or bipolar
    • Not caused by substance use
• Schizophreniform Disorder:
  • Diagnosed using the following criteria:
    • Presence of delusions, hallucinations, disorganised speech, disorganised behaviour and negative symptoms
    • The symptoms have lasted more than a month but less than 6 months
    • The symptoms are not caused by another disorder such as depression or bipolar
    • Not caused by substance use
• Schizophrenia:
  • Diagnosed using the following criteria:
    • Presence of delusions, hallucinations, disorganised speech, disorganised behaviour and negative symptoms
    • The symptoms have significantly impaired the person’s functioning and they cannot live a normal life (for example, they can’t look after their personal hygiene)
    • The symptoms have lasted more than 6 months
    • The symptoms are not caused by another disorder such as depression or bipolar
    • Not caused by substance use
• Schizoaffective Disorder:
  • A combination of a mood disorder (affective) and psychosis.
  • It must be specified as a depressive or bipolar type.
  • The symptoms are:
    • The presence of a major mood episode (depression or mania)
    • The presence of delusions or hallucinations for more than 2 weeks when not depressed or manic
    • The symptoms meet the criteria for a mood disorder
    • Not caused by substance use
• Substance / Medication Induced Psychotic disorder:
  • This is diagnosed using the following criteria:
    • The presence of hallucinations or delusions
    • The symptoms develop during or soon after substance intoxication or withdrawal
    • The symptoms are not better explained by another psychotic disorder or delirium
    • The symptoms cause significant impairment in functioning
    • The substances in question is one or more of the following:
      • Alcohol
      • Cannabis
      • Phencyclidine (PCP) and other hallucinogens (mushrooms, LSD)
      • Sedative, hypnotic or anxiolytic (benzos, codeine, sleeping tablets)
      • Amphetamine or other stimulant (Ritalin, diet pills)
      • Cocaine
  • Important Notes:
    • A substance/medication–induced psychotic disorder is characterised by hallucinations and/or delusions due to the direct effects of a substance or withdrawal from a substance.
    • Every person has a unique physiology.
    • For this reason, a substance may affect one person in a way that is different from the next.
    • The risks and dangers of substance use and abuse can vary based on a person’s gender, genetic disposition, physical and mental health, and other factors.
    • It is also important to note that any substance taken in very large quantities over a long enough period can lead to a psychotic state.
• The following can lead to a psychotic episode:
  • Intoxication:
    • Alcohol
    • Amphetamine and related substances
    • Cannabis
    • Cocaine
    • Hallucinogens
    • Inhalants
    • Opioids (meperidine)
    • Phencyclidine and related substances
    • Sedatives, hypnotics, and anxiolytics
    • Other or unknown substances
  • Withdrawal:
    • Alcohol
    • Sedatives
    • Hypnotics and anxiolytics
    • Other or unknown substances
• Over-the-counter or prescription drugs may cause psychotic symptoms – these are pseudoephedrine, phenylephrine, muscle relaxants, anticonvulsants, antihistamines, chemotherapeutic agents, and certain antidepressant medications.
• Most substance-induced psychotic symptoms are short lived and to resolve with sustained abstinence along with other symptoms of substance intoxication and withdrawal.
• Certain drugs may result in more prolonged psychotic episodes – for example, psychosis triggered by amphetamines, cocaine or PCP may persist for weeks.
• If the psychotic episode is a result of withdrawal, it is especially important that a person seek medical help immediately.
• Unaccompanied withdrawal from certain substances may be very dangerous and even deadly.
• In most of cases, treatment should extend beyond that which treats the substance-induced psychotic disorder.
• Even if a person is no longer experiencing an episode, the presence of it suggests what could be a serious and underlying substance abuse disorder.

Bipolar and Related Disorders

• You will see clients who have Bipolar Disorder as they tend to use substances when they are manic or to self-medicate when they are depressed.
• Bipolar disorders can be seen as a bridge between psychotic and depressive disorders.
• The disorder was first identified in the 1850s by a French psychiatrist, Jean-Pierre Falret, who called it ‘la folie circulaire’ or ‘circular insanity.
• He used this term to describe the cyclical depressive and manic episodes experienced by Bipolar sufferers.
• Bipolar Disorder was later called Manic-Depressive Disorder because it represents the two poles or mood opposites of mania and depression.
• Moods can be seen as existing on a spectrum, like below:
• There are three types of Bipolar Mood Disorders:
  • Type I is the more severe – it is characterised by alternating episodes of depression and mania. The person’s functioning is severely impaired.
  • Type II is less severe – it is characterised by alternating episodes of hypomania and depression. The person is still able to function relatively well.
  • Cyclothymic Disorder is less severe – it is characterised by alternating periods of hypomanic and depressive symptoms but these are not severe enough to warrant a diagnosis of Bipolar Type I or II.

Manic Episode:

Mania is defined as a period of:

• Abnormal and persistently elevated, expansive or irritable mood
• Increased goal directed activity
• Increased energy levels
• Decreased need for sleep
• Being more talkative or talking louder and faster than normal (called pressure of speech)
• Feeling like your thoughts are racing (called flight of ideas)
• Being easily distracted
• Inflated self-esteem or grandiosity (feeling godlike)
• Engaging in risky behaviours that could have severe consequences (binge drinking, risky sex, shopping sprees)

Hypomanic Episode:

• Hypomania is also known as “little mania”.
• It is less severe than full blown mania and the person can function.
• It is defined as a period of:
  • Inflated self-esteem
  • Decreased need for sleep
  • Pressure of speech
  • Flight of ideas
  • Increase in goal directed behaviour
  • Distractibility
  • Engagement in risky activities

Depressive Episode:

• Depression is indicated by the following:
  • Low mood for most of the day and for more days than not
  • Diminished interest in activities (apathy)
  • Decreased pleasure in things that used to be enjoyed (anhedonia)
  • Weight loss or gain
  • Insomnia (not sleeping) or hypersomnia (sleeping too much)
  • Fatigue and low energy levels
  • Restlessness or feeling ‘slowed down’ or ‘heavy’
  • Feelings of worthlessness, hopelessness and helplessness
  • Decreased concentration and indecisiveness
  • Recurrent thoughts of death (suicidal ideation) or suicidality
• Bipolar symptoms can be caused by substance use or medication.
• The symptoms are the same as Type I or II but they start during or soon after intoxication or withdrawal.
• Substance / Medication Induced Bipolar Disorder can be caused by:
  • Alcohol
  • Phencyclidine
  • Other hallucinogens
  • Sedatives, hypnotics or anxiolytics
  • Amphetamines
  • Cocaine

Specifiers for Bipolar Mood Disorders

• With anxiety (mild, moderate, severe)
• Mixed features (depression and mania / hypomania)
• Current manic episode
• Current depressive episode
• Rapid cycling (used when the person has experienced 4 major mood episodes in the last 12 months)
• With psychotic features (when delusions or hallucinations are present)
• Peripartum onset (when the symptoms manifest after a birth)
• With seasonal pattern (where depressive and manic episodes coincide with the changing of the seasons, specifically summer and winter)

Depressive Disorders

• Depressive disorders are characterised by a low mood, sad or empty feelings, irritability, changes in vegetative functioning (sleeping patterns, appetite, energy levels, weight gain or loss) and cognitive changes that significantly impair the person’s daily functioning.
• You are very likely to see clients with a depressive disorder, either as a cause or because of substance use.
• There are several depressive disorders:
  • Disruptive Mood Dysregulation Disorder:
    • Presence of the following symptoms for at least 12 months:
    • Recurrent temper outbursts (+/- 3 times a week)
    • Mood is generally angry or irritable
    • For more than 12 months
    • In 2 settings at least (e.g. home and school)
    • Age of onset before 10 years
    • Symptoms not better accounted for by one of the neurodevelopmental disorders (e.g. ODD or CD)
  • Major Depressive Disorder:
    • 5 or more of the following symptoms present for 2 weeks:
    • Depressed mood
    • Anhedonia
    • Weight loss or gain
    • Insomnia or hyposomnia
    • Psychomotor agitation or retardation
    • Fatigue or loss of energy
    • Feelings of worthlessness, helplessness and / hopelessness
    • Recurrent thoughts of dying or suicidality or parasuicide (suicide attempt)
    • Significant impairment in daily functioning
  • Persistent Depressive Disorder (Dysthymia):
    • 5 or more of the following symptoms present for at least 2 years:
    • Low mood
    • Poor appetite or overeating
    • Insomnia or hyposomnia
    • Low energy or fatigue
    • Low self-esteem
    • Poor concentration
    • Difficulty making decisions
    • Feelings of hopelessness
    • Not caused by a substance or medication
    • Not better explained by a diagnosis of Schizoaffective Disorder, Delusional Disorder or other psychotic disturbance
    • Significant distress of impairment in functioning
  • Premenstrual Dysphoric Disorder (low mood associated with menstruation):
    • 5 or more of the following symptoms occurring in most menstrual cycles:
    • Marked lability (mood swings)
    • Irritability or anger
    • Interpersonal conflict
    • Low mood
    • Anxiety
    • Anhedonia
    • Difficulty concentrating
    • Lethargy, fatigue or low energy
    • Change in appetite
    • Insomnia or hyposomnia
    • Feeling overwhelmed or ‘out of control’
    • Breast tenderness, bloating, joint or muscle pain, headaches
  • Substance / Medication Induced Depressive Disorder:
    • Prominent and persistent low mood during or after substance or medication use
    • Not better explained by a depressive disorder or delirium (symptoms do not precede substance use)
    • Causes significant impairment in daily functioning
    • Can be caused by: alcohol, phencyclidine, other hallucinogens, inhalants, opioids, sedatives, anxiolytics, hypnotics, amphetamines and cocaine
  • Depressive Disorder Due to Medical Condition:
    • Prominent and persistent low mood based on a biological cause and where the stressor is a serious medical condition (for example, cancer, HIV or thyroid problems)
    • Not better accounted for