DSM-IV Exam 1

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Basic features of DSM-IV as presented in class and in text (4): 1. Categorical classification of mental disorders
2. Descriptive in approach
-atheoretical except when causation known
-descriptions based on identifiable behaviors
3. Disorders of unknown etiology are grouped according to shared clinical features.
4. Multi-axial classification system
Components of multiaxial classification system: Axis I: All clinical disorders except personality disorders and mental retardation

Other conditions that may be a focus of clinical attention
Components of multiaxial classification system: Axis II: Personality Disorders

Mental retardation
Components of multiaxial classification system: Axis III: General Medical Condition

(only physician can dx, verify, "client reports")

ICD-9-CM codes
Components of multiaxial classification system: Axis IV: Psychosocial and Environmental Problems

Stressors for past year

-relevant to treatment
-very brief statement (specific example)
Components of multiaxial classification system: Axis V: Global assessment of functioning

-1-100; 0=no information
-current, highest in past year
-consider psychological, social and occupational functioning on a hypothetical continuum of mental health-illness
-start at top; worse than next?
-symptom severity and level of functioning
Rules for multiple diagnoses: Primary diagnosis=primary reason for treatment

Axis I=assumed to be primary unless specified otherwise

Axis II primary="primary dx" "reason"

Multiple w/in axis=list in order of focus
No diagnosis (Axis I or II): V71.09 code
Diagnosis deferred (Axis I or II): 799.99 code
Limitations of DSM-IV-TR (cont.): Applies only to individuals
Limitations to DSM-IV: Apply cautiously to people from non-Western cultures

Based on white, male, middle-class American

Appendix I: cultural formulation; cultural bound syndromes
Limitations to DSM-IV (cont.): Ethnic/culture: nuances of different cultures (may look psychotic)

Dx is only one step in comprehensive evaluation
affect: Pattern of observable behaviors that is the expression of subjectively experienced feeling state (emotion)

Ex: sadness, elation, anger

In contrast to mood (more pervasive, sustained emotional climate) affect is more fluctuating changes in emotional weather

Normal range of expression of affect varies within and among cultures

Disturbances in affect: blunted, flat inappropriate, labile, restricted or constricted
blunted affect: significant reduction in intensity of emotional expression
flat affect: absence or near absence of any signs of affective expression
inappropriate affect: discordance between affective expression and content of speech or ideation
labile affect: abnormal variability in affect with repeated, rapid and abrupt shifts in affective expression
restricted or constricted affect: mild reduction in range and intensity of emotional expression
Recognize examples of Appendix C terms: :O)
agitation (psychomotor agitation): excessive motor activity associated with a feeling of inner tension. Activity is usually nonproduntive and repetitious. Consists of behavior i.e. pacing, fidgeting, wringing hands, pulling clots, inability to sit still.
agonist medication: chemical entity extrinsic to endogenously produced substances that acts on a receptor and is capable of producing the maximal effect that can be produced by stimulating that receptor
partial agonist: capable only of producing less than maximal effect even when given in concentration sufficient to bind with all available receptors
agonist/antagonist medication: chemical entity extrinsic to endogenously produced substances that acts on a family of receptors (mu, delta, kappa opiate receptors) in such a fashion that it is an agonist or partial agonist on one type of receptor and an antagonist on another
alogia: impoverishment in thinking that is inferred from observing speech and language behavior. May be brief, concrete replies to questions and restrictions in the amount of spontaneous speech (poverty of speech). Sometimes speech is adequate in amount but conveys little information because it is overconcrete, overabstract, repetitive, stereotyped (poverty of content)
amnesia: loss of memory

2 types: anterograde, retrograde
anterograde amnesia: loss of memory of events that occur after the onset of etiological condition or event
retrograde amnesia: loss of memory of events that occurred before onset of etiological condition or agent
antagonist medication: chemical entity extrinsic to endogenously produced substances that occupies a receptor, produces no physiologic effects and prevents endogenous and exogenous chemicals from producing effect on that receptor
anxiety: apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic symptoms of tension. The focus of anticipated danger may be internal or external
aphasia: an impairment in understanding or transmission of ideas by language in any of its forms-reading, writing, speaking-due to injury or disease of brain centers involved in language
aphonia: iniability to produce speech sounds that required the use of the larynx that is not due to a lesion in the central nervous system
ataxia: partial or complete loss of coordination of voluntary muscular movement
attention: ability to focus in a sustained manner on a particular stimulus or activity. Disturbance may be manifested by easy distractability or difficulty finishing tasks or concentrating on work.
avolition: An inability to initiate and persist in goal-directed activity. When severe enough to be pathological, is pervasive, prevents person from completing different types of activities (e.g. work, intellectual pursuits, self-care).
catalepsy: Waxy flexibility--rigid maintenance of a body position over an extended period of time
cataplexy: Episodes of sudden bilateral loss of muscle tone resulting in individual collapsing, often in association with intense emotions such as laughter, anger, fear, surprise.
catatonic behavior: Marked motor abnormalities including motori immobility (i.e. catalepsy or stupor), certain types of excessive motor activity (apparently purposeless agitation not influenced by external stimuli), extreme negatism (apparent motiveless resistance to instructions or attempts to be moved) or mutism, posturing or stereotyped movements and echolia or echopraxia.
conversion symptom: Loss of, or alteration in, voluntary motor or sensory functioning suggesting a neurological or general medical condition. Psychological factors are judged to be associated with the development of the symptom. The symptom is not fully explained by neurological or general medical condition or direct effects of a substance. Symptom is not intentionally produced or feigned; not culturally sanctioned.
defense mechanism: Automatic psychological process that protects individual against anxiety and from awareness of internal or extrenal stressors or dangers. Mediate individual's reaction to emotional conflicts and external stressors. Some (e.g. projection, splitting, acting out) are almost invariably maladaptive. Others (suppression, denial) are maladaptive or adaptive depending on severity, inflexibility, context.
delusion: False belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. Belief is not ordinarily accepted by other members of the person's culture/subculture (e.g. not part of religious faith). When false belief involves value judgment, it is regarded as a delusion only when judgment is so extreme as to defy credibility. Delusional conviction occurs on continuum, can sometimes be inferred from an individual's behavior. Often difficult to distinguish between a delusion and an overvalued idea (in which case individual has unreasonable belief or ida but does not hold it as firmly as is the case with a delusion).

Subdivided according to content.
bizarre delusion: Involves a phenomenon that the person's culture would regard as totally implausible.
delusional jealousy: Delusion that one's sexual partner is unfaithful.
erotomatic delusion: Delusion that another person, usually of higher status, is in love with the individual.
grandiose delusion: Delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person.
delusion of being controlled: Feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than being under one's control.
delusion of reference: Delusion whose theme is that events, objects, or other persons in one's immediate environment have a particular and unusual signifance.

Usually of a negative or pejorative nature, but also may be grandiose in content. Differs from an idea of refernce, in which the false belief is not as firmly held nor as fully organized into a true belief.
persecutory delusion: The central theme is that one (or someone to whom who is close) is being attacked, harassed, cheated persecuted, or conspired against.
somatic delusion: Main content pertains to the appearance or functioning of one's body.
thought broadcasting delusion: Delusion that one's thoughts are being broadcast out loud so that they can be perceived by others.
thought insertion delusion: Delusion that certain of one's thoughts are not one's own, but rather are inserted into one's mind.
depersonanalization: Alteration in perception or experience of the self so that one feels detached form, and as if one is an outside observer of, one's mental processes or body (e.g. feeling like one is in a dream).
derailment ("loosening of association"): Pattern of speech in which a person's ideas slip off one track onto another that is completely unrelated or only obliquely related. Moving from one sentence or clause to another, person shifts topic idiosyncratically from one frame of reference to another and things may be said in juxtaposition that lack meaningful relationship. Occurs between clauses, in constrast to incoherence, which is within clauses.

Occasional change of topic without warning or obvious connection does not constitute derailment.
derealization: Alteration in perception or experience of the external world so that it seems strange or unreal (e.g. people may seem unfamiliar or mechanical).
disorientation: Confusion about the time of day, date, or season (time), where one is (place), or who one is (person).
dissociation: The individual deals with emotional conflict or internal or external stressors with a breakdown in the usually integrated functions of consciousness, memory, perception of self or the environment, or sensory/motor behavior.
distractability: Inabiltiy to maintain attention--shifting from one area or topic to another with minimal provocation, or attention being drawn too frequently to unimportant or irrelevant external stimuli.
dysarthria: Imperfect articulation of speech due to disturbances of muscular control.
dyskinesia: Distortion of voluntary movements with involuntary muscular activity.
dyssomnia: Primary disorders of sleep or wakefulness characterized by insomnia or hypersomnia as the major presenting symptoms.

Disorders of amount, quality, timing of sleep.
dystonia: Disordered tonicity of muscles.
echolalia: Pathological, parrotlike, apparrently senseless repetition (echoing) of a word or phrase just spoken by another person.
echopraxia: Repetition by imitation of the movements of another. Action is not a willed or voluntary one; has semiautomatic and uncontrollable quality.
flashback: Recurrence of a memory, feeling or perceptual experiences from the past.
flight of ideas: Nearly continuous flow of accelerated speech with abrupt changes from topic to topic that are usually based on understandable associations, distracting stimuli or plays on words.

When severe speech may be disorganized and incoherent.
gender dysphoria: Persistent aversion toward some or all of those physical characteristics or social roles that connote one's own biological sex.
gender identity: Person's inner conviction of being male or female.
gender role: Attitudes, patterns of behavior, personality attributes defined by culture in which the person lives as stereotypically "masculine" or "feminine" social roles.
grandiosity: An inflated appraisal of one's worth, power, knowledge, importance, or identity.

When extreme, may be of delusional proportions.
hallucination: A sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of relevant sensory organ. Distinguished form illusions (actual external stimulus is misperceived or misinterpreted). Person may or may not have insight into the fact that he is having a hallucination.

Not ordinarily applied to the false perceptions that occur during dreaming, while falling asleep (hypnogogic), awakening (hypnopompic).

Transient hallucinatory experiences may occur in people without a mental disorder.
auditory hallucination: Perception of sound, most commonly voices.

Some clinicians and investigators would not include those experiences perceived as coming from insided the head and would instead limit the concept of true auditory hallucinations to those sounds whose source is perceived as being external.

As used in DSM-IV, no distinction is made as to whether source of voices is perceived as being inside or outside the head.
gustatory hallucination: Involving the perception of taste (usually unpleasant),
olfactory hallucination: Perception of odor, such as of burning rubber or decaying fish.
somatic hallucination: Percpetion of a physical experience localized within the body (such as a feeling of electricity).

Distiguished from physical sensations arising from an as-yet undiagnosed general medical condition, from hypochondriacal preoccupation with normal physical sensations and from tactile hallucination.
tactile hallucination`: Perception of being touched or of something being under one's skin.

Most common are sensation of electric shock and formication (sensation of something creeping or crawling on or under the skin).
visual hallucination: Involveing sight, which may consist of formed images, such as people, or unformed images, such as flashes of light.

Distinguished from illusions, which are misperceptions of real external stimuli.
hyperacusis: Painful sensitivity to sounds.
hypersomnia: Excessive sleepiness, as evidenced by prolonged nocturnal sleep, difficulty maintaining an alert awak state during the day, or undesired daytime sleep episodes.
ideas of reference: The feeling that casual incidents and external events have a particular and unusual meaning that is specific to the person.

Distinguished form delusion of reference, in which there is a belief that is help with delusional conviction.
illusion: A misperception or misinterpretation of a real external stimulus, such as hearing the rustling leaves as the sounds of voices.

See also hallucinations.
incoherence: Speech or thinking that is essentially incomprehensible to others because words or phrases are joined together without a logical or meaningful connection.

Disturbance occurs within clauses, in contrast to derailment whcih is between clauses.

Sometimes been referred to as "word salad" to convey degree of linguistic disorganization.

Mildly ungrammatical constructions or idiomatic usages characteristic of particular regional or cultural backgrounds, lack of education, or low intelligence should not be considered incoherence.

Term is generally not applied where there is evidence that the disturbance is due to aphasia.
insomnia: A subjective complaint of difficulty falling or staying asleep or poor sleep quality.

3 types of insomnia.
initial insomnia: Difficulty in falling asleep.
middle insomnia: Awakening in the middle of the night followed by eventually falling back to sleep, but with difficulty.
terminal insomnia: Awakening before one's usual waking time and being unable to return to sleep.
intersex condition: A condition in which an individual shows intermingling, in various degress, of the characteristics of each sex, including physical form, reproductive organs, and sexual behavior.
macropsia: The visual perception that objects are larger than they actually are.
magical thinking: The erroneous belief thatone's thoughts, words, or actions will cause or prevent a specific outcome in some way that defies commonly understood laws of cause and effect.

May be a part of normal child development.
micropsia: The visual perception that objects are smaller than they actually are.
mood: A pervasive and sustained emotion that colors the perception of the world.

Ex: depression, elation, anger, anxiety

In contrast to affect, which refers to more fluctuating changes in emotional "weather," mood is more pervasive, sustained emotional "climate."

5 types of moods.
dysphoric mood: Unpleasant mood, such as sadness, anxiety, irritability
elevated mood: An exaggerated feeling of well-being, euphoria, elation.

May describe feeling high, ecstatic, on top of the world, up in the clouds.
euthymic mood: Mood in the "norma" range, which implies the abscence of depressed or elevated mood.
expansive mood: Lack of restraint in expressing one's feelings, frequently with an overvaluation of one's significance or importance.
irritable: Easily annoyed and provoked to anger.
mood-congruent psychotic features (mood-congruent delusion and mood-congruent hallucination): Delusions of hallucinations whose content is entirely consistent with the typical themes of a depressed or manic mood.

Content of delusions or hallucinations involves themes of . . .

If depressed mood: personal inadequacy, guilt, disease, death, nihilism, deserved punishment.

If manic mood: inflated worth, power, knowledge, identity, special relationship to a deity or famous person.

Content of the delusion may include themes of persecution if these are based on concepts such as inflated worth or deserved punishment.
mood-incongruent psychotic features (mood-incongruent delusion and mood-incongruent hallucination): Delusions of hallucinations whose content is NOT consistent with the typical themes of a depressed or manic mood.

Content of delusions or hallucinations would NOT involved themes of . . .

If depressed mood: personal inadequacy, guilt, disease, death, nihilism, deserved punishment.

If manic mood: inflated worth, power, knowledge, identity, special relationship to a deity or famous person.

Ex: persecutory delusions (with self-derogatory or grandiose content), thought insertion, thought broadcasting, delusions of being controlled who content has no apparent relationship to any of the themes listed above.
nystagmus: Involuntary rhythmic movements of the eyes that consist of small-amplitude rapid tremors in one direction and a large, slower, recurrent sweep in the opposite direction.

May be horizontal, vertical, or rotary.
overvalued idea: An unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. person is able to acknowledge possibility that belief may not be true).

Belief is not one that is ordinarily accepted by other members of the person's culture or subculture.
panic attacks: Discrete periods of sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom.

During attacks, symptoms such as shortness of breath, smothering sensations, palpitations, pounding heart, accelerated heart rate, chest pain or discomfort, choking, fear of going crazy or losing control.

May be unexpected (uncued), onset of attck is not associated with a situational trigger and instead occurs "out of the blue"; situationally bound, unvariably occurs immediately on exposure to, or in anticipation of, a situational trigger (cue); situationally predisposed, more likely to occur on exposure to a situataional trigger but is not invariably associated with it.
paranoid ideation: Ideation, of less than delusional proportions, involving suspisiousness or the belief that one is being harassed, persecuted, or unfairly treated.
parasomnia: Abnormal behavior of physiological events occurring during sleep or sleep-wake transitions.
personality: Enduring patterns of perceiving, relating to, and thinking about the environment and oneself.
personality traits: Prominent aspects of personality that are exhibited in a wide range of important social and personal contexts.

Only when traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress do they constitude a Personality Disorder.
phobia: A persistent, irrational fear of a specific object, activity, or situation (the phobic stimulus) that results in a compelling desire to avoid it.

Often leads either to avoidance of phobic stimulus or to enduring it with dread.
pressured speech: Speech that is increased in amount, accelearated, difficult or impossible to interrupt. Usually it is also loud and emphatic.

Frequently person talks without any social stimulation and may continue to talk even though no one is listening.
prodrome: An early or premonitory sign or symptom of a disorder.
psychomotor retardation: Visible generalized slowing of movements and speech.
psychotic: Historically received number of different definitions, none of which has achieved universal acceptance.

Narrowest definition: delusions or prominent hallucinations, with hallucinations occuring in absense of insight into their pathological nature.

Slightly less restrictive: also includes prominent hallucinations that the individual realizes are hallucinatory experiences.

Broader: also includes other positive symptoms of Schizophrenia (i.e. disorganized speech, grossly disorganized or catatonic behavior).

DSM-II and ICD-9 (far too inclusive, focused on severity of functional impairment): impairment that grossly interferes with capacity to meet ordinary demands of life

Defined conceptually: loss of ego boundaries or a gross impairment in reality testing.

Based on these characteristic features, different disorders in DSM-IV emphasize different aspects of various definitions of psychotic.
residual phase: Phase of an illness that occurs after remission of the florid symptoms or the full syndrome.
sex: A person's biological status as male, female, or uncertain. Depending on the circumstances, this determination may be based on the appearance of the external genitalia or karyotyping.
sign: An objective manifestation of a pathological condition.

Observed by examiner rather than reported by the affected individual.
stereotyped movements: Repetitive, seemingly driven and nonfunctional motor behavior (e.g. hand shaking or waving, body rocking, head banging, mouthing of objects, self-biting, picking at skin or body orifics, hitting one's own body).
psychosocial stressor: Any life event or life change that may be associated temporally (and perhaps causually) with the onset, occurence, or exacerbation of a mental disorder.
stupor: A state of unresponsiveness with immobility and mutism
symptoms: A subjective manifestation of a pathological condition.

Symptoms are reported by the individual rather than observed by the examiner.
syndrome: A grouping of sign and symptoms, based on their frequent co-occurence, that may suggest a common underlyign pathogenesis, course, familial pattern, or treatment selection.
synesthesia: A condition in which a sensory experience associated with one modality occurs when another modality is stimulated (e.g. a sound produces that sensation of a particular color).
tic: An involtary, sudden, rapid, recurrent, nonrhythmic, stereotped motor movement or vocalization.
transsexualism: Severe gender dysphoria, coupled with persistent desire for the physical characteristics and social roles that connote the opposite biological sex.
acting out: Individual deals with emotional conflict or internval or external stressors by actions rather than reflections or feelings.

Broader definition than original concept of acting out of transference feelings or wishes during psychotherapy and is intended to include behavior arising both within and outside the transference relationship.

Defensive acting out is not synonymous with "bad behavior" because it requires evidence that the behavior is related to emotional conflicts.
affiliation: The individual deals with emotional conflict or internal or external stressors by turning to others for help or support.

Involves sharing problems with others but does not imply trying to make someone else responsible for them.
altruism: The individual deals with emotional conflict or internal or external stressors by dedication to meeting the needs of others. Unlike the self-sacrifice sometimes characterisitc of reaction formation, the individual receives gratification either vicariously or from the response of others.
anticipation: The individual deals with emotional conflict or internal or external stressors by experienceing emotional reactions in advance of, or anticpating consequences of, possible future events and considering realistic, alternative responses or solutions.
autistic fantasy: The individual deals with emotional conflict or internal or external stressors by excessive daydreaming as a substitue for human relationships, more effective action, or problem solving.
denial: The individual deals with emotional conflict or internal or external stressors by refusing to acknowledge some painful aspect of external reality or subjective experience that owuld be apparent to others.

The term psychotic denial is used when there is gross impairment of reality testing.
devaluation: The individual deals with emotional conflict or internal or external stressors by attributing exaggerated negative qualities to self or others.
displacement: The individual deals with emotional conflict or internal or external stressors by transferring a feeling about, or response to, one object onto another (usually less threatening) substitute object.
help-rejecting complaining: The individual deals with emotional conflict or internal or external stressors by complaining or makig repetitious requests for help that disguise covert feelings of hostility or reproach toward others, which are then expressed by rejecting the suggestions, advice or help that others offer.

The complaints or requests may involved physical or psychological symptoms or life problems.
humor: The individual deals with emotional conflict or internal or external stressors by emphasizing the amusing or ironic aspects of the conflict or stressor.
idealization: The individual deals with emotional conflict or internal or external stressors by attributing exaggerated positive qualities to others.
intellectualization: The individual deals with emotional conflict or internal or external stressors by the excessive use of abstract thinking or the making of generalizations to control or minimize disturbing feelings.
isolation of affect: The individual deals with emotional conflict or internal or external stressors by separation of ideas from the feelings originally associated with them.

The individual loses touch with the feelings associated with a given idea (e.g. a traumatic event) while remaining aware of the cognitive elements of it (e.g. descriptive details).
omnipotence: The individual deals with emotional conflict or internal or external stressors by feeling or acting as if he possesses special powers or abilities and is superior to others.
passive aggression: The individual deals with emotional conflict or internal or external stressors by indirectly and unassertively expressing aggression toward others. There is a facade of overt compliance masking covert resistance, resentment, or hostility.

Often occurs in response to demands for independent action or performance or the lack of gratification of dependent wishes but may be adaptive for individuals in subordinate positions who have no other way to express assertivenss more overtly.
projection: The individual deals with emotional conflict or internal or external stressors by falsely attributing to another his own unacceptable feelings, impulses, or thoughts.
projection identification: As in projection, the individual deals with emotional conflict or internal or external stressors by falsley attributing to another his own unacceptable feelings, impulses or thoughts.

Unlike simple projection, individual does not fully disavow what is projected. Instead, remains aware of his or her own affects or impulses but misattributed them as justifiable reactions to the other person.

Not frequently, individual induces the very feelings in others that were first mistakenly believed to be there, making it difficult to clarify who did what to whom first.
rationalization: The individual deals with emotional conflict or internal or external stressors by concealing the true motivations for his own thoughts, actions or feelings through the elaboration of reassuring or self-serving but incorrect explanations.
reaction formation: The individual deals with emotional conflict or internal or external stressors by substituting behavior, thoughts, or feelings that are diametrically opposed to his own unacceptable thoughts or feelings (this usually occurs in conjunction with their repression).
repression: The individual deals with emotional conflict or internal or external stressors by expelling disturbing wishes, thoughts, or experiences from conscious awarenss. The feeling component may remain conscious, detached from its associated ideas.
self-assertion: The individual deals with emotional conflict or internal or external stressors by expressing his feelings and thoughts directly in a way that is not coercive or manipulative.
self-observation: The individual deals with emotional conflict or internal or external stressors by reflecting on his own thoughts, feelings, motivation and behavior and responding appropriately.
splitting: The individual deals with emotional conflict or internal or external stressors by compartmentalizing opposite affect states and failing to integrate the positive and negative qualities of self or others into cohesive images.

Because ambivalent affects cannot be experienced simutaneously, more balanced views and expectations of self or others are excluded from emotional awareness.

Self and object images tend to alternate between polar opposites: exclusively loving, powerful, worthy, nurturant, and kind--or exclusively bad, hateful, angry, destructive, rejecting, or worthless.
sublimation: The individual deals with emotional conflict or internal or external stressors by channeling potentially maladaptive feelings or impluses into socially acceptable behavior (e.g. contact sports to channel angry impuluses).
suppression: The individual deals with emotional conflict or internal or external stressors by intentionally avoiding thinking about disturbing problems, wishes, feelings or experiences.
undoing: The individual deals with emotional conflict or internal or external stressors by words or behavior designed to negate or to make amends symbolically for unacceptable thoughts, feelings or actions.

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