I.
Anxiety, Trauma, and Stressor-Related and
Abnormal Psychology
AUGUST 2016
PSYCHOMETRICIAN LICENSURE EXAM
Prepared by Kay Vardeleon, MA, RPm, CSCOP
Warning: This material is protected by Copyright Laws. Unauthorized used
shall be prosecuted in the full extent of the Philippine Laws. For exclusive use
of CBRC reviewees only.
What is Abnormal Behavior?
It is a psychological dysfunction within an individual that is
associated with distress or impairment in functioning and a
response that is not typical or culturally expected.
Psychological Dysfunction is a breakdown in cognitive,
emotional and behavioral functioning.
Presenting Problem: reason why the person came to the
clinic.
Clinical Description: unique combination of behavior, thoughts
and feelings that make up a specific disorder.
Prevalence: how many in the population as a whole have the
disorder
Incidence: how many new cases occur during a given period
such as a year
Course: pattern of the illness over time
Chronic course which means they tend to last a long
time, even a lifetime.
Episodic course which means the individual is likely
to recover within a few months only to suffer a
recurrence of the disorder at a later time.
Time Limited Course which means that the disorder
will improve without treatment in a relatively short
period.
Onset: how a disorder starts or begins
Acute onset which means they begin suddenly
Insidious onset which means they develop gradually
over an extended period
Prognosis: the anticipated course of a disorder
Prognosis is good means the individual will
probably recover
Prognosis is guarded means the probable outcome
doesnt look good
Etiology: a study of origins, has to do with why a disorder
begins (what causes it) and includes biological, psychological
and social dimensions.
Diasthesis-Stress Model: individuals inherit tendencies to
express certain traits and behaviours, which may then be
activated under conditions of stress.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
Obsessive-Compulsive and Related
Disorders
TERMS:
Fear: is an immediate alarm reaction to danger
Anxiety: is a future-oriented mood state characterized by
apprehension because we cannot predict or control upcoming
events.
Panic Attack: brief experience of intense fear or acute
discomfort, accompanied by physical symptoms that usually
include heart palpitations, chest pains, shortness of breath,
and possibly dizziness.
Expected (or cued) e.g. if you know that you are
afraid of high places, but not anywhere else
Unexpected (or uncued): if you have no idea when
the next attack will come.
ANXIETY DISORDERS:
1. Generalized Anxiety Disorder
At least 6 months of excessive anxiety and worry,
must be ongoing more days than not, and is difficult
to turn off or control.
People with GAD mostly worry about minor,
everyday life events, a characteristic that
distinguishes GAD from other anxiety disorders
For children only one symptom is required for a
diagnosis of GAD
2. Panic Disorder and Agoraphobia
Panic Disorder: individuals experience severe,
unexpected panic attacks; they may think theyre
dying or losing control
Most, but not all panic disorder, is accompanied by
Agoraphobia which is fear and avoidance of
situations in which a person feels unsafe or unable to
escape to get home or to a hospital in the event of
developing panic symptoms
Susto: In Latin America, this is a disorder
characterized by sweating, increased heart rate, and
insomnia but not by reports of anxiety and fear even
though fright is the cause.
Ataque de Nervios: Among Hispanic-Americans,
particularly those from the Carribean, this disorder
presents with symptoms that are similar to panic
attack but associated more often with crying
uncontrollably and bursting into tears.
CAUSES OF ANXIETY DISORDERS:
Biological
We inherit a tendency to be tense, uptight and
anxious
Depleted levels of Gammaaminobutyric acid(GABA)
is associated with increased anxiety
Area associated with anxiety is the limbic system
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 Psychological:
Parents who are overprotective and intrusive
A general sense of uncontrollability may develop
due to upbringing and other disruptive or traumatic
environmental factors.
Social
Stressful life events trigger our biological and
psychological vulnerabilities to anxiety
TREATMENTS:
Benzodiazepines are most prescribed for GAD, as
well as some antidepressants
Cognitive Behavioral Therapy: patients evoke worry
process during therapy sessions and confront
anxiety-provoking images and thoughts head on.
Meditational approaches help patients become more
tolerant of distressing thoughts and feelings
3. Specific Phobia
Is an irrational fear of a specific object or situation
that markedly interferes with a persons ability to
function.
Four major subtypes:
a) Blood-injection-injury type:
b) Situational type (e.g. planes, elevators, and
enclosed spaces)
c) Natural environment type (e.g heights, storm
and water)
d) Animal type
e) Other --- for any phobias that dont fall under the
first 4 subtypes
CAUSES:
Traumatic conditioning experience play a role
Fear is most likely to develop if we are prepared;
that is, we seem to carry an inherited tendency to
fear situations that have always been dangerous to
the human race such as being threatened by wild
animals or an enclosed space
We also have to be susceptible to developing anxiety
about the possibility that the event will happen again.
Patients with blood phobia probably inherit a strong
vasovagal response that makes them susceptible to
fainting.
TREATMENT:
Structured and consistent exposure-based exercises
4. Separation Anxiety Disorder
Characterized by childrens unrealistic and persistent
worry that something will happen to their parents or
other important people in their life or that something
will happen to the children themselves that will
separate them from their parents.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
5. Social Anxiety Disorder (social phobia)
Marked fear or anxiety about one or more social
situations in which the person is exposed to possible
scrutiny by others.
In Japan, a variant is Taijin Kyofusho in which
individuals may believe they have horrendous bad
breath or body odor and thus avoid social interaction.
CAUSES:
We learn quickly to fear angry expressions than
other facial expressions
We could inherit a generalized biological vulnerability
to develop anxiety or to be socially inhibited or both
Real social trauma resulting in true alarm e.g. severe
bullying in childhood
People with SAD also learned growing up that social
evaluation can be dangerous creating a
psychological vulnerability to develop anxiety.
TREATMENT:
Cognitive Therapy that emphasize real-life
experiences to disprove perception of danger
6. Selective Mutism
Rare childhood disorder characterized by a lack of
speech in one or more settings in which speaking is
socially expected.
Failure to speak is not because of lack of knowledge
of speech or any physical difficulties, nor is it due to
another disorder in which speaking is rare or can be
impaired such as Autism Spectrum Disorder
Must occur for more than one month and cant be
limited to the first month of school.
TREATMENT:
Cognitive Behavioral Therapy but with emphasis on
speech
TRAUMA AND STRESS-RELATED DISORDERS
1. Post Traumatic Stress Disorder
PTSD is the diagnosis given to severe anxiety
experienced after exposure to a traumatic event.
Duration is more than one month
PTSD can occur immediately after a traumatic event,
or after a significant time has passed. The latter kind
is of PTSD is called PTSD with delayed onset.
Setting is often exposure to a traumatic event during
which an individual experiences or witnesses death,
actual or threatened serious injury, or actual or
threatened sexual violation.
CAUSES:
Precipitating event: someone personally experiences
trauma
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 A family history of anxiety suggests a generalized
biological vulnerability for PTSD
A generalized psychological vulnerability based on
early experiences with unpredictable or
uncontrollable events e.g. family instability
If you have a strong social support around you, it is
much less likely you will develop PTSD after trauma
TREATMENT:
Victims should face the original trauma, process
intense emotions and develop effective coping
procedures in order to overcome the debilitating
effects of the disorder (catharsis, imaginal exposure)
Structured interventions delivered as soon after the
trauma are useful in prevention of PTSD
2. Acute Stress Disorder
Diagnosis given to PTSD, or very much like it,
occurring within the first month of trauma, but the
different name emphasizes the severe reaction that
people have immediately.
Almost 50% of people with Acute Stress Disorder go
on to develop PTSD.
3. Adjustment Disorders
Describe anxious or depressive reactions to life
stress that are generally milder than what one would
see in Acute Stress Disorder or PTSD but are
nevertheless impairing in terms of interfering with
work or school performance, interpersonal
relationships, or other areas of living.
If symptoms persist for more than six months after
the removal of the stress, the adjustment disorder
would be considered as chronic.
4. Attachment Disorders
Disturbed and developmentally inappropriate
behaviors in children, emerging before 5 years of
age, in which the child is unable or unwilling to for
normal attachment relationships with caregiving
adults.
These seriously maladaptive patterns are due to
inadequate or abusive child-rearing practices.
Two kinds:
A) Reactive Attachment Disorder: the child will very
seldom seek out a caregiver for protection,
support, and nurturance and will seldom
respond to offers from caregivers to provide this
kind of care. Generally they would evidence lack
of responsiveness, limited positive affect and
additional heightened emotionality such as
fearfulness or intense sadness.
B) Disinhibited Social Engagement Disorder:
pattern of behavior in which the child shows no
inhibitions whatsoever to approaching adults.
Child will engage in inappropriately intimate
behavior by showing a willingness to
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
accompany and unfamiliar adult figure
somewhere without first checking back with a
caregiver.
OBSESSIVE COMPULSIVE AND RELATED
DISORDERS
1. Obsessive-Compulsive Disorders
Obsessive-Compulsive Disorder (OCD) is a
common, chronic and long-lasting disorder in which
a person has uncontrollable, reoccurring thoughts
(obsessions) and behaviors (compulsions) that he or
she feels the urge to repeat over and over.
Obsessions: intrusive and mostly non-sensical
thoughts, images or urges that an individual tries to
resist or eliminate.
Compulsions: are the thoughts or actions used to
suppress the obsessions and provide relief.
Four major types of obsessions:
a) Symmetry (most common)
b) Forbidden thoughts and actions
c) Cleaning and Contamination
d) Hoarding
It is common for tic disorder, characterized by
involuntary movements (sudden jerking of limbs for
example) to co-occur in patients with OCD
(particularly children) or in their families.
More complex tics with involuntary vocalizations are
referred to as Tourettes disorder.
CAUSES:
Clients with OCD equate thoughts with specific
actions or activity of thoughts called thought-action-
fusion
Generalized biological and psychological
vulnerability (e.g believing some thoughts must be
suppressed) must be present before development of
the disorder
TREATMENT:
Medication, especially those that prevent the
reuptake of serotonin such as chloripamine or SSRIs
Exposure and Ritual Prevention (ERP): process
whereby the rituals are actively prevented and
patient is systematically and gradually exposed to
the feared thoughts or situations
Cognitive Treatments, with focus on the
overestimation of threat, the importance of control of
intrusive thoughts, sense of inflated responsibility
present in patients with OCD who think they alone
are tasked with preventing a catastrophe, as well as
the need for perfectionism
5. Body Dysmorphic Disorder
Preoccupation with some imagined defect in
someone who actually looks reasonably normal.
Disorder is referred to as imagined ugliness
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TREATMENTS:
Same with OCD, drugs that prevent the reuptake of
serotonin and CBT
6. Other ObsessiveCompulsive and Related
Disorders
A. Hoarding Disorder: The three major characteristics of
this problem are excessive acquisition of things,
difficulty discarding anything, and living with
excessive clutter under conditions characterized as
gross disorganization.
B. Trichotillomania (hair pulling disorder). The urge to
pull ones hair from anywhere in the body including
the scalp, eyebrows and arms.
C. Excoriation (Skin Picking Disorder). Repetitive and
compulsive picking of the skin leading to tissue
damage.
TREATMENT:
Trichotillomania and Excoriation is helped by habit
reversal training where patients are carefully taught
to be more aware of their repetitive behavior,
particularly just as it's about to begin, and substitute
a different behavior such as chewing gum or some
other reasonably pleasurable but harmless behavior.
II. Somatic Symptoms and Related
Disorders and Dissociative Disorders
SOMATIC SYMPTOMS:
1. Somatic Symptom Disorder
formerly called Briquets Syndrome and Somatoform
Disorder
Involves having a significant focus on physical
symptoms such as pain or fatigue to the point
that it causes major emotional distress and problems
functioning.
Life revolves around symptom, they are the persons
identity
The person may or may not have another diagnosed
medical condition
2. Illness Anxiety Disorder
Formerly known as hypochondriasis
Physical Symptoms are either not experienced at the
present time or are very mild but severe anxiety is
focused on the possibility of having or developing a
serious disease
Koro: belief, accompanied by severe anxiety and
sometimes panic, that the genitals are retracting into
the abdomen
CAUSES:
Somatic Symptom Disorder and Illness Anxiety
Disorder are disorders of cognition or perception with
strong emotional contributions. Faulty interpretations
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
of physical signs and sensations are central -
learned.
There is a modest genetic contribution, such as a
tendency to overrespond to stress
TREATMENT:
Little is known about treating this disorders
Reassurance and education seems to be effective in
some cases
3. Conversion Disorder (Functional Neurological
Symptom Disorder)
Physical malfunctioning such as paralysis, blindness or
difficulty speaking (aphonia) without any physical or
organic pathology to account for the malfunction.
Not so easy to distinguish from malingering (faking).
Conversion symptoms are often seen to be
precipitated by marked stress.
La Belle Indifference was long thought of as a
hallmark of conversion reactions but this is not always the
case
CAUSES:
Unconscious mental processes
[Freud] Causes of conversion disorders
Primary gain reduction of anxiety when anxiety gets
converted to physical symptom; accounts for much of la
belle indifference
Secondary gain increased attention and sympathy
from loved ones, and also being allowed to avoid a
difficult situation or task
TREATMENT:
Identify and attend to traumatic or stressful life event
Reduce reinforcing or supportive consequences of
the conversion symptom
4. Factitious Disorder
Falls somewhere between malingering and
conversion disorders
Symptoms are under voluntary control but there is no
obvious reasons for voluntarily producing the
symptoms except possibly to assume the sick role
and receive increase attention.
When an individual deliberately makes someone
else sick, the condition is called factitious disorder
imposed on another, previously known as
Manchausen Syndrome by proxy
DISSOCIATIVE DISORDERS
Two Kinds of Dissociative Experiences:
Depersonalization: your perception alters so that you
temporarily lose the sense of your own reality, as if you were
in a dream and you were watching yourself.
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Derealization: your sense of reality of the external world is TREATMENTS:
lost. Things may seem to change shape or size; people may Identify cues and triggers that provoke memories of
seem dead or mechanical. trauma and neutralize them
Confront and relive early trauma to gain control over
1. Depersonalization Derealization Disorder horrible events
When feelings are so severe that they dominate an
individuals life and prevent normal functioning. III. Mood Disorders and Suicide
7. Dissociative Amnesia
Major Depressive Episode
The inability to recall important autobiographical
Extremely depressed mood state that last at least two
information, usually of a traumatic or stressful nature
weeks and includes cognitive symptoms (such as
that is inconsistent with ordinary forgetting
feelings of worthlessness or indecisiveness) and
Two types:
disturbed physical functions (such as altered sleeping
a) Generalized amnesia: unable to remember
pattern, significant changes in appetite or weight, or a
anything including who they are
notable loss of energy) to the point that even the
b) Localized or selective amnesia: failure to recall
slightest activity or movement requires an overwhelming
specific events, usually traumatic, that occur
amount effort.
during a specific period.
Anhedonia: loss of energy or inability to engage in
Dissociative Fugue: memory revolves around a
pleasurable activities or have any fun
particular incident --- and an unexpected trip. Usually
they leave behind an intolerable situation.
Manic Episode
Amok: individuals in this trancelike state often
A distinct period of abnormally and persistently
brutally assault or sometimes kill people and
elevated, expansive or irritable mood and
animals. If the person is not killed himself, he
abnormally and persistently increased goal directed
probably wont remember the incident
activity or energy, lasting at least 1 week and present
Among people of the arctic, Amok is called
most of the day, nearly every day or any duration if
pivloktoq. Among Navajo Indians its called frenzy
hospitalization is necessary.
witchcraft.
1. Major Depressive Disorder
TREATMENT:
Also called clinical depression, this disorder causes
Individuals who experience dissociative amnesia or
severe symptoms that affect how you feel, think, and
fugue state do get better on their own and remember
handle daily activities, such as sleeping, eating, or
what they have forgotten
working. To be diagnosed with clinical depression,
Episodes are so clearly related to life stress that
the symptoms must be present for at least two
prevention of future episodes involves therapeutic
weeks.
resolution of distressing situation and increasing
If two or more major depressive episodes occurred
strength of personal coping mechanism
and was separated by at least 2 months during
For more difficult cases, hypnosis or
which the individual was not depressed, the major
benzodiazepines have been used
depressive disorder is being noted as recurrent.
Persistent depressive disorder (dysthymia) shares
8. Dissociative Identity Disorder
many of the symptoms of major depressive disorder
People with this condition may adopt as many as
but differs in its course. There may be fewer
100 new identities, all simultaneously co-existing,
symptoms but depression remains relatively
although the average number is closer to 15.
unchanged over long periods of time, sometimes 20
Alters: shorthand term for the different identities or
to 30 years or more. Dysthymia is defined as
personalities in DID.
depressed mood that lasts at least 2 years during
Host: The person who becomes the patient and asks
which the patient cannot be symptom-free for more
for treatment
than 2 months at a time even though they may not
The original person is seldom the person who seeks
experience all of the symptoms of a major
treatment.
depressive episode.
Memories tend to be different from one alter to the
Double depression: persistent depression with fewer
next.
symptoms (dysthymia) eventually followed by a
Major Depressive Episode.
CAUSES:
In addition to classifying depression as mild,
Being horribly, often unspeakably, abused as a child
moderate and severe, clinicians use eight basic
Suggestibility can also play a role.
specifiers to describe depressive disorders:

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098 - 5

 a) With psychotic features (mood congruent or
mood incongruent)
b) With anxious distress (mild to severe)
c) With mixed features (have at least 3 symptoms
of mania)
d) Melancholic features specifier (including severe
somatic features e.g. weight loss, loss of libido,
e) Catatonic features specifier (including catalepsy
or absence of movement)
f) Atypical features specifier
g) Peripartum onset specifier (before or after birth)
h) Seasonal pattern specifier (episodes that occur
during certain seasons,also called seasonable
affective disorder)
A side note: From Grief to Depression
Integrated Grief: the finality of death and its
consequences are acknowledged and the individual
adjusts to the loss. New, bittersweet, but mostly positive
memories of the person that are no longer dominating or
interfering with functioning are then incorporated into
memory.
Complicated Grief: Struggles to accept the reality of death,
wishes to protest against it. Feeling disconnected from the
world. With somatic distress and pangs of sadness.
2. Other Depressive Disorders
Premenstrual Dysphoric Disorder: severe and
sometimes incapacitating emotional reactions during
the premenstrual period.
Disruptive Mood Dysregulation Disorder: Used to
diagnose children and adolescents who exhibit
symptoms usually associated with Bipolar Disorder
Not Otherwise Specified. Symptoms include severe
irritability or temper tantrums, but no episodes of
severe mania.
3. Bipolar Disorders
Tendency of manic episodes to alternate with Major
Depressive episodes in an unending rollercoaster
ride from the peaks of elation to the depths of
despair.
2 Types:
a) Bipolar I Disorder: major depressive episodes
alternate with full manic episodes
b) Bipolar II Disorder: major depressive episodes
alternate with hypomanic episodes instead of full
manic episodes.
Cyclothymic Disorder: chronic alteration of mood
elevation and depression that does not reach the
severity of manic or major depressive episodes.
Rapid Cycling Specifier: at least 4 manic or
depressive episodes in a year
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
Rapid Switching or Rapid Mood Switching: Patience
cycle between depression and mania without any
break. Associated with higher suicide rates.
CAUSES OF MOOD DISORDERS:
BIOLOGICAL
Mood disorders are hereditable (as evidenced by
twin studies)
Low levels of serotonin is a cause, but only in
relation to other neurotransmitters like
norepinephrine and dopamine. Serotonins apparent
function is to regulate our emotional reactions
Overactivity in the hypothalamic-pituitary-
adrenocortical (HPA) axis which produces stress
hormones like cortisol have also been implicated
PSYCHOLOGICAL:
Stressful life events are strongly related to the onset
of mood disorders
[Seligman] Learned helplessness theory of
depression: the depressive attributional style is (a)
internal, in that the individual attributes negative
events to personal failings, (b) stable, in that even
after a particular negative event passes, additional
bad things will always be my fault remains. (c)
global, in that attributions extend in a variety of
issues.
[Beck] Depressive Cognitive Triad: negative view of
self, world and future
Although bipolar disorder is equally distributed
among males and females, 70% of those with major
depressive disorder and dysthymia are women.
Source is cultural; men are encouraged to be
independent, masterful and assertive while females
in contrast are more passive, sensitive and relies on
others more than makes do.
SOCIAL:
Social support is important in determining course of
mood disorders
TREATMENTS OF MOOD DISORDERS
Antidepressants which has four types:
(a) selective serotonin reuptake inhibitors (SSRIs)
which block presynaptic reuptake of serotonin.
Example: fluoxetine (Prozac)
(b) mixed reuptake inhibitors,
(c) monoamine oxidase (MAO) inhibitors which
block the enzyme MAO which breaks down
neurotransmitters such as norepinephrine and
serotonin
Lithium Carbonate, a mood stabilizing drug, remains
the gold standard for treating Bipolar Disorder
Cognitive Behavioral Therapy by Aaron Beck to
challenge unhelpful ways of thinking and behaving
Interpersonal Therapy by Myrna Weissman and
Gerald Klerman which focuses on resolving
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 problems in existing relationships and learning to
form important new interpersonal relationships
Interpersonal and Social Rhythm Therapy (ISRT) , a
treatment for Bipolar Disorder, regulates circadian
rhythms by helping patients regulate their eating and
sleeping cycles and other daily schedules, as well as
cope more effectively with stressful life events,
particularly interpersonal issues.
STEPPS (Systems Training for Emotional
Predictability and Problem Solving): participants
learn new language in thinking about their disorders
with others in their systems
IV. Eating and Sleep-Wake Disorders
EATING DISORDERSd
1. Bulimia Nervosa
Eating a large amount of foodtypically more junk
food than fruits and vegetables --- than most people
will eat under similar circumstances.
Just as important as the amount of food eaten is that
the eating experience is considered as out of control.
Another important criterion is that the individual
attempts to compensate for the binge-eating and the
potential weight gain, almost always by purging
techniques.
The distinction between purging type (e.g. vomiting,
laxative and diuretics) and the non-purging type (e.g.
exercise and or fasting) was dropped in the DSM 5
because the non-purging type is quite rare.
2. Anorexia Nervosa
People are so successful at losing weight they put
their lives in danger
They have an intense fear of obesity and relentlessly
pursue thinness. DSM 5 specifies that Anorexics are
those with 15% below ideal body weight
DSM 5 Types:
a) Restricting Type: individual diet to limit calorie
intake.
b) Purging Type: rely on purging. (Unlike those
with bulimia, binge-eating purging Anorexics
binge on relatively small amounts of food and
purge more consistently, in some cases each
time they eat.)
Anorexics generally suffer from poor body image
3. Binge-Eating Disorder
Individuals who experience marked distress because
of binge eating but do not engage in extreme
compensatory behaviors
Was a disorder under study in DSM IV TR but
became a full-fledged disorder in DSM V
CAUSES OF EATING DISORDERS
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
Anorexia and particularly Bulimia are the most
culturally specific psychological disorders yet
identified glorification of slenderness in society
Typical family of someone with anorexia is
successful, hard-driving, concerned about external
appearances, and eager to maintain harmony
Eating disorders seem to run in families, but it is not
clear what is inherited. Speculation is emotional
stability and poor impulse control are the genetic
predispositions for eating disorders.
Young girls with eating disorders have diminished
sense of personal control in their own abilities and
talents, and a strikingly low self-esteem
TREATMENTS:
Drug treatments have not been found effective for
anorexia nervosa but antidepressants seem to work
for Bulimia.
Short Term CBT: targets problem eating behaviors
and associated attitudes about the overriding
importance and significance of body weight and
shapes
In Anorexia, the goal is to restore the patients weight
to at least within the low average range. If the patient
refuses to eat, inpatient treatment is recommended.
SLEEP-WAKE DISORDERS
Sleep-Wake Disorders are divided into two categories:
a) Dyssomnias : difficulties in getting enough sleep, problems
with sleeping when you want to and complaints about
the quality of sleep.
b) Parasomnias: Abnormal behavioural or physiological
events that occur during sleep, such as nightmare and
sleepwalking.
4. Insomnia Disorder
Actually applies to a number of complaints e.g.
difficulty initiating sleep, difficulty maintaining sleep,
and non-restorative sleep.
5. Hypersomnolence Disorder
Involve sleeping too much
6. Narcolepsy
a condition characterized by an extreme tendency to
fall asleep whenever in relaxing surroundings.
Some with narcolepsy experience cataplexy, a
sudden loss of muscle tone which lasts from several
seconds to several minutes and is usually preceded
by strong emotion such as anger or happiness
Cataplexy result from a sudden onset of REM sleep
2 characteristics of people with Narcolepsy
a) Sleep paralysis: a brief period after awakening
when they cant move or speak and is often
frightening to those who go through it
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 b) Hypnogogic Hallucinations: vivid and often
terrifying experiences that begin at the start of
sleep and are said to be unbelievably realistic
because they include not only visual aspects but
also touch, hearing, and even the sensation of
body movement.
7. Breathing Related Sleep Disorders
Sleepiness during the day or disruptive sleep at night
that has a physical origin namely problems with
breathing while asleep
Breathing while asleep could be labored
(hypoventilation) or extreme that they stop breathing
altogether called sleep apnea.
3 Types of Sleep Apnea:
a) Obstructive Sleep Apnea Hypopnea Syndrome
which occurs when airflow stops despite
continued activity by the respiratory system.
Obesity is somewhat related to this syndrome.
b) Central Sleep Apnea which involves complete
cessation of respiratory activities for brief
periods and is associated with central nervous
system disorders
c) Sleep-related hypoventilation which is a
decrease in airflow without a complete pause in
breathing.
8. Circadian Rhythm Sleep Disorder
Characterized by disturbed sleep (either insomnia or
excessive sleepiness during the day) brought about
by the brains inability to synchronize its sleep
patterns with the current patterns of day and night
Several types
a) Jet lag type: cause by rapidly crossing multiple
timezones
b) Shift work type: associated with work schedules
c) Delayed sleep phase type: Sleep is delayed
later than normal bedtime
d) Advanced sleep wake type: early to bird, early to
rise
e) Irregular sleep wake type: people who
experience varied sleep cycles
f) Non-24 hour sleep wake type: sleeping on 25 or
26 hour cycles and sleeping and sleeping later
each day.
Scientists believe that the hormone melatonin, also
called the Dracula Hormone contributes to setting
our biological clocks and tells us to sleep.
TREATMENTS FOR SLEEP-WAKE DISORDERS
Phototherapy: using bright light to trick the brain into
readjusting the biological clock.
Phase delays (moving bedtime later) and phase
advances (moving bedtime earlier) seems to work.
Sleep hygiene: changes in lifestyle such as avoiding
caffeine and nicotine , or going to bed at a specific
time each day.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
Scheduled awakenings, or waking a child briefly
approximately 30 minutes before a typical episode
occurs, can help in night terrors.
Relaxation exercises and medical interventions have
also helped.
V. Sexual Dysfunctions, Paraphilic
Disorder, and Gender Dysphoria.
SEXUAL DESIRE DISORDERS
1. Male Hypoactive Sexual Desire Disorder
little or no interest in any type of sexual activity
among men.
2. Female Sexual Interest/ Arousal Disorder
little or no interest in any type of sexual activity
among men.
SEXUAL AROUSAL DISORDERS
1. ERECTILE DISORDER
Problem is not desire but becoming physically
aroused.
For men, it is reflected by an inability to become rigid
for penetration, for females it is inability to achieve
sufficient lubrication.
The old and somewhat derogatory terms are
impotence and frigidity, but they are imprecise
labels.
Erectile Dysfunction increases rapidly after age 60
2. Orgasm Disorders
Inability to achieve orgasm despite adequate sexual
desire and arousal is commonly seen in women and
less commonly seen in men.
Males who achieve orgasm only with great difficulty
or not at all meet the criteria for a condition called
delayed ejaculation. In women, the condition is
referred to as female orgasmic disorder.
SEXUAL PAIN DISORDERS
1. Genito-pelvic pain/penetration disorder
A disorder specific to women which refers to
difficulties with penetration during attempted
intercourse or significant pain during intercourse.
Most common presentation is vaginismus: pelvic
muscles in the outer third of the vagina undergo
involuntary spasms when intercourse is affected.
PARAPHILIC DISORDERS
PARAPHILIC DISORDERS
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 Disorders of sexual arousal that cause distress or
impairment to the individual or cause personal harm
or risk of harm to others.
NOTE: DSM V does not consider a paraphilia a
disorder unless it is associated with distress and
impairment or harm or the threat of harm to others.
1. FETIHISTIC DISORDER
A person is sexually attracted to non-living objects.
There are many types of fetishes as there are
objects
3 classes of objects or activities:
a) Inanimate object
b) Source of specific tactile stimulation e.g. rubber,
c) Part of the body e.g. foot, buttocks (called
partialism)
2. VOYEURISTIC AND EXHIBITIONISTIC DISORDER
Voyeuristic Disorder: is the practice of observing, to
become aroused, an unsuspecting individual
undressing or naked.
Exhibitionistic Disorder: Achieving sexual arousal
and gratification by exposing genitals to
unsuspecting strangers.
3. TRANSVESTIC DISORDER
Sexual arousal is strongly associated with the act of
(or fantasies of) dressing in clothes of the opposite
sex or cross-dressing
4. SADISM AND SEXUAL MASOCHISM DISORDERS
Both are associated with either inflicting pain or
humiliation (sadism) or suffering pain or humiliation
(masochism), and becoming sexually aroused is
associated specifically with violence and injury in
these conditions.
Hypoxiphilia: self-strangulation to reduce the flow of
oxygen to the brain and enhance the sensation of
orgasm.
5. SADISTIC RAPE
Many rapists meet the criteria for Antisocial
Personality Disorder
Rapes are described as opportunistic: an aggressive
or antisocial individual with a marked lack of
empathy or disregard for inflicting pain on others (as
opposed to planned rapes out of vindictiveness or
anger)
GENDER DYSPHORIA
Gender Dysphoria
is present if a persons physical sex (male or female
anatomy also called natal sex) is not consistent
with a persons sense of who he or she really is or
with his or her experienced gender
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
If natal sex is female but the experienced gender is
strongly male, the individual is referred to as a
transsexual man or transman. A natal male would be
a transwoman.
If they have undergone sex reassignment surgery,
then they are called post transition.
Gender dysphoria can occur among individuals with
Disorder of Sexual Development, formerly known as
intersexuality or hermaphroditism, who are born with
ambiguous genitals.
ASSESSING AND TREATING PARAPHILIC
DISORDERS:
Covert sensitization: patients associate sexually
arousing images in their imagination with some
reasons why the behavior is harmful or dangerous
Orgasmic Reconditioning: patients are instructed to
masturbate to their usual fantasies but to substitute
more desirable ones before ejaculating
Drug Treatments: Most popular drug used is an
antiandrogen called cyproterone acetate. This form
of chemical castration eliminates sexual desire and
fantasy
VI. SUBSTANCE-RELATED, ADDICTIVE
AND IMPULSE CONTROL DISORDER
Substance-related and addictive disorders: which are
associated with the abuse of drugs and other substances
people take to alter the way they think, feel and behave.
A new addition to this category in the DSM V is gambling
disorder.
Impulse Control Disorders: represent a number of related
problems that involve the inability to resist acting on a
drive or temptation.
Levels of Involvement:
a) Substance Use: is the ingestion of psychoactive
substances in moderate amounts that does not
significantly interfere with social, educational and
occupational functioning.
b) Intoxication: our physiological reactions to ingested
substances --- drunkenness or getting high.
c) Substance Abuse: defined in terms of how
significantly it interferes with a users life.
d) Substance Dependence: the person is
physiologically dependent on the drug or drugs,
requires increasingly greater amounts of the drug to
experience the same effect (tolerance) and will
respond physically in a negative way when the
substance is no longer ingested (withdrawal). Can
also be defined in terms of drug seeking behaviors.
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 * DSM IV considered substance abuse and substance use
as 2 separate diagnosis. DSM V combined the two based
on the research that they co-occur.
Substance:
chemical compounds that are ingested to alter mood
or behavior.
Six categories:
a) Depressants: substances that result in
behavioural sedation and can induce relations.
Includes: alcohol, barbiturates, and
benzodiazepines.
b) Stimulants: substances that cause users to be
more active and alert and can elevated mood.
Example: amphetamines, cocaine, nicotine and
caffeine.
c) Opiates: major effect is to produce analgesia
temporarily (reduce pain) and euphoria.
Example: heroin, opium, codeine, and morphine.
d) Hallucinogens: Substances that can alter
sensory perception and can produce delusions,
paranoia, and hallucinations. Cannabis and LSD
and included in this category.
e) Other Drugs of Abuse: Drugs abused that does
not fit neatly into the above categories.
Example: anabolic steroids and other over the
counter medications.
f) Gambling Disorder: As with ingestion of the
substances just described, individuals who
display gambling disorder are unable to resist
the urge to gamble, which in turn, results in
negative consequences e.g. divorce, loss of
employment.
IMPULSE CONTROL DISORDERS
Intermittent Explosive Disorder: Clients have episode
in which they act on their aggressive impulses that
results in serious assaults or destruction of property.
Kleptomania: a recurrent failure to resist urges to
steal things that are not needed for personal use or
for their monetary value.
Pyromania: an impulse-control disorder that involves
having an irresistible urge to set fires.
VII. PERSONALITY DISORDERS
Personality Disorder: a persistent pattern of emotions,
cognitions, and behavior that results in enduring emotional
distress for the person affected and/or for others and may
cause difficulties in work and relationships.
Cluster A: Odd or Eccentric Disorders
Paranoid Personality Disorder: a pervasive distrust
and suspiciousness such that their motives are
interpreted as malevolent.
Schizoid Personality Disorder: A pervasive pattern of
detachment from social relationships and a restricted
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
range of expression and emotion in interpersonal
settings.
Schizotypal Personality Disorder: A pervasive
pattern of social and interpersonal deficits marked by
acute discomfort with reduced capacity for close
relationships as well as by cognitive and perceptual
distortions and eccentricities of behavior.
Cluster B: Dramatic, Emotional or Erratic Disorders
Antisocial Personality Disorder: A pervasive pattern
of disregard for and violation of the rights of others.
Borderline Personality Disorder: A pervasive pattern
of instability of interpersonal relationships, self-
image, affects, and control over impulses.
Histrionic Personality Disorders: A pervasive pattern
of excessive emotion and attention seeking.
Narcissistic Personality Disorders: A pervasive
pattern of grandiosity (in fantasy or behavior), need
for admiration, and lack of empathy.
Cluster C: Anxious or Fearful Disorders
Avoidant Personality Disorder: A pervasive pattern of
social inhibition, feelings of inadequacy and
hypersensitivity to negative evaluation.
Dependent Personality Disorder: a pervasive and
excessive need to be taken cared of, which leads to
submissive and clinging behavior and fears of
separation.
Obsessive Compulsive Personality Disorder: A
pervasive pattern of preoccupation with orderliness,
perfectionism, and mental and interpersonal control,
at the expense of flexibility, openness and efficiency.
TREATMENTS:
Borderline Personality has been helped by the
Dialectical Behavior Therapy which involves helping
people cope with stressors that seem to trigger
suicidal behaviors
VIII. SCHIZOPHRENIA SPECTRUM AND
OTHER PSYCHOTIC DISORDERS
Early figures in diagnosing schizophrenia:
a) In 1809, John Haslam described schizophrenia
symptoms as a form of insanity in his book
Observations on Madness and Melancholy. At the
same Haslam was writing his description in England,
Philippe Pinel was writing his description in France.
b) Benedict Morel used the French term demence (loss
of mind) and precoce (premature) to describe
schizophrenia because onset is usually during
adolescence.
c) Emil Kraepelin built on the writings of Haslam, Pinel
and Morel to give us the most enduring description
and categorization of schizophrenia. He combined
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 symptom usually considered as separate and question) and loose association or derailment
combined them in a diagnosis called dementia (abruptly changing topics of conversation to
praecox: unrelated areas).
- Catatonia (alternating immobility and excited b) Inappropriate Affect: laughing or crying at
agitation) improper times.
- Hebephrenia (silly and immature emotionality) c) Bizarre behavior e.g. hoarding objects or acting
- Paranoia (delusions of grandeur and in unusual ways in public. This also includes
persecution) catatonia (motor dysfunctions that range from
d) Swiss psychiatrist Eugen Bleuler introduced the term wild agitation to immobility) and waxy flexibility
schizophrenia. Schizophrenia comes from the Greek (tendency to keep bodies and limbs in a position
words for split (skhizein) and mind (phren) reflecting placed by someone else.) DSM 5 now includes
Bleulers belief that underlying all unusual behaviors catatonia as a separate schizophrenia spectrum
shown by people with this disorder was an disorder.
associative splitting of basic personality.
2) Schizophreniform Disorder
SCHIZOPHRENIA SPECTRUM DISORDERS: Diagnosis given to patients who experience the
symptom of schizophrenia for a for a few months
1) Schizophrenia
only; they can usually resume normal lives.
Characterized by a broad spectrum of cognitive and
Symptoms sometimes sometimes disappear as a
emotional dysfunctions including delusions and
result of successful treatment, sometimes they do so
hallucinations, disorganized speech and behavior
for reasons unknown.
and inappropriate emotion.
DSM 5 Diagnostic Criteria include onset of psychotic
Most mental health workers distinguish between
symptoms within weeks of the first noticeable
positive and negative symptoms of schizophrenia. A
change in behavior, confusion at the height of
third dimension, disorganized symptoms, also
psychotic episode, good premorbid social and
appears to be an important aspect of the disorder.
occupational functioning and absence of blunted or
Positive Symptoms refer to symptoms that distort
flat affect.
reality
a) Delusion: a belief that most members of society
3) Schizoaffective Disorder
would consider a misrepresentation of reality.
Symptoms of schizophrenia but with characteristics
E.g. delusion of grandeur (mistaken belief that
of mood disorders (depression or mania)
person is famous or powerful), delusion of
persecution (mistaken belief that others are out
4) Delusional Disorder
to get them), and even unusual ones like the
Major feature is persistent belief that is contrary to
Capgras Syndrome (belief in which a person
reality , in the absence of other characteristics of
thinks someone he or she knows has been
schizophrenia.
replaced by a double) and Cotards Syndrome
DSM 5 recognizes the following delusional subtypes:
(in which the person believes he or she is dead).
a) Erotomanic type: irrational belief that one is
b) Hallucination: experience of sensory events
loved by another person usually one of higher
without input from the environment, most
status
common of which are auditory hallucinations.
b) Grandiose type: believing in ones inflated self-
Negative Symptoms refers to deficits in normal
worth, power, knowledge or special relationship
behavior such as in areas of speech, blunted affect,
to a deity or famous person
and motivation.
c) Jealous type: belief that sexual partner is
a) Avolition: inability to initiate and persist in
unfaithful.
activities. Also called apathy, people with this
d) Persecutory type: belief that ones self (or
symptom show little interest in even in the most
someone close) is being malevolently treated in
basic day-to-day functions including those
some way.
associated with personal hygiene.
e) Somatic delusions: person feels afflicted by
b) Alogia: relative absence of speech
physical defect or general medical condition
c) Anhedonia: presumed lack of pleasure
Previous versions of DSM include a separate
experienced by people
delusional disorder: shared psychotic disorder (folie
d) Affect flattening: not showing emotions when
a deux). DSM V now includes this type of delusion
you would normally expect to
with a specifier to indicate that the delusion is
Diorganized symptoms include rambling speech,
shared.
erratic behavior, and inappropriate affect.
a) Disorganized Speech. Example tangentiality
5) Brief Psychotic Disorder
(going off on a tangent instead of answering a
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098 - 11
 Characterized by the presence of one or more
positive symptoms such as delusions, hallucinations
or disorganized speech or behavior lasting 1 month
or less.
Proposed Disorder Under Study in DSM V:
6) Attenuated Psychosis Syndrome
Diagnosis given to people who experience psychotic
symptoms but are sufficiently distressed enough to
seek help from mental health professionals (ergo
patients have awareness of the troubling and bizarre
nature of their symptoms).
This maybe an early stage of schizophrenia, called
prodromal.
IX. NEURODEVELOPMENTAL
DISORDERS
Neurodevelopmental Disorder
Disorders that show themselves early in life often
persists as a person grows older so the term
childhood disorders is often misleading. Because the
developmental disorders in this group are all
presumed to be neurologically based, DSM V
categorizes them as neurodevelopmental disorders.
1. Attention-Deficit and Disruptive Behavioral Disorders
Attention Deficit and Hyperactivity Disorder: a pattern
of inattention, such as being disorganized or
forgetful, about school or work-related tasks, or of
hyperactivity and impulsivity.
a) DSM V refers to two categories of symptoms:
- Inattention
- Hyperactivity and Impulsivity
b) Genetic evidence reveal that ADHD and
learning disabilities may share a common cause
Conduct Disorder: repetitive and persistent pattern of
behavior in which the basic rights of others or major
age appropriate societal norms or rules are violated.
a) Two subtypes: childhood-onset (onset is prior t o
age 10) and adolescent-onset (absence of
symptom prior to age 10).
b) DSM V adds a subtype with callous-
unemotional presentation) to show that client
presents in a way that shows characteristics
similar to adults with psychopathy.
Oppositional Defiant Disorder: a pattern of
angry/irritable mood, argumentative/defiant behavior,
or vindictiveness lasting at least six months."
2. Communication and Learning Disorders
Language disorder: a childs delay in using spoken
and written language and is characterized by small
vocabulary, grammatically incorrect sentences,
and/or trouble understanding words or sentences.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
Social (pragmatic) communication disorder: Despite
adequate vocabulary and the ability to create
sentences, patients have trouble with the practical
use of language; their conversational interactions
tend to be inappropriate.
Speech sound disorder. Correct speech develops
slowly for the patients age or dialect.
Childhood-onset fluency disorder (stuttering). The
normal fluency of speech is frequently disrupted.
Specific Learning Disability: A significant discrepancy
between a persons academic achievement and what
would be expected from someone of the same age --
- referred to by some as unexpected
underachievement
a) Clinicians can use specifiers such as disorders
of reading, written expression or mathematics to
highlight specific problems for remediation
b) Disorders of reading can still be broken down
into: problems with word recognition (difficulty
decoding single words sometimes called
dyslexia), fluency (problems being able to read
words and sentence smoothly and
automatically) and comprehension (difficulty
getting meaning from what is read).
c) Historically, a specific learning disorder is
defined as 2 standard deviations between
achievement and IQ
3) Autism Spectrum Disorder
Is a neurodevelopmental disorder that at its core
affects how one perceives and socializes with others.
DSM V combines most of the disorders previously
included under the umbrella term pervasive
developmental disorders (e.g. autistic disorder,
aspergers disorder, and childhood disintegrative
disorder) and included them into this one category.
Rett Disorder, a condition that affects mostly females
is also classified under ASD
Two major characteristics of ASD:
a) Impairments in social communication and social
interaction
b) Restricted, repetitive patterns of behavior,
interests or activities.
DSM V also recognizes that impairments are present
in early childhood and that they limit daily
functioning.
DSM V introduced 3 levels of severity:
a) Level 1 Requiring Support
b) Level 2 Requiring Substantial Support
c) Level 3 Requiring Very Substantial Support
4) Intellectual Disability (Intellectual Development
Disorder)
A disorder evident in childhood as significantly below
average intellectual and adaptive functioning.
DSM V identified difficulties in 3 domains:
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 a) Conceptual (e.g. skill deficits in areas such as
language, reasoning, knowledge, and memory.)
b) Social (e.g problems with social judgment and
the ability to make and retain friendships)
c) Practical (e.g. problems managing personal care
or job responsibilities)
DSM IV TR previously used the term mental
retardation but this was changed in DSM V to
intellectual disability to be consistent in changes in
terminology in the field.
Those with severe forms of ID may never learn
speech as communication
The DSM V criteria for ID no longer include numeric
cut-offs for IQ scores, which were present in
previous versions to de-emphasize these numbers in
place of comprehensive assessment of functioning.
But before the following was standard as four levels
of ID:
a) Mild: IQ score between 50-55 and 70
b) Moderate: IQ score 35-40 to 50-55
c) Severe: ranging from 20-35 to 35-40
d) Profound: with scores below 20-25
Classification of levels of support needed by a
person with an ID is intermittent, limited, extensive,
and pervasive
Down Syndrome: Most common chromosomal form
of ID caused by the presence of an extra 21st
chromosome which is why it is sometimes called
trisomy 21.
Global Developmental Delay: Used when a child
under the age of 5 seems to be falling behind
developmentally but you cannot reliably assess the
degree.
5) Tic and Motor Disorders
Developmental coordination disorder. The patient is
slow to develop motor coordination; some also have
attention-deficit/hyperactivity disorder or learning
disorders.
Stereotypic movement disorder. Patients repeatedly
rock, bang their heads, bite themselves, or pick at
their own skin or body orifices.
Tourettes disorder. Multiple vocal and motor tics
occur frequently throughout the day in these
patients.
Persistent (chronic) motor or vocal tic disorder. A
patient has either motor or vocal tics, but not both.
Provisional tic disorder. Tics occur for no longer than
1 year.
Other or unspecified tic disorder. Use one of these
categories for tics that do not meet the criteria for
any of the preceding.
6) Disorders of Eating, Sleeping and Elimination
Pica: The patient eats material that is not food
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
Rumination disorder: There is persistent
regurgitation and chewing of food already eaten.
Encopresis: At age 4 years or later, the patient
repeatedly passes feces into clothing or onto the
floor.
Enuresis: At age 5 years or later, there is repeated
voiding of urine (it can be voluntary or involuntary)
into bedding or clothing.
Non-rapid eye movement sleep arousal disorder,
sleep terror type: During the first part of the night,
these patients cry out in apparent fear. Often they
dont really wake up at all. This behavior is
considered pathological only in adults, not children
7) Other Disorders or Conditions That Begin in the
Developmental Period
Disruptive mood dysregulation disorder. A childs
mood is persistently negative between severe
temper outbursts.
X. NEUROCOGNITIVE DISORDERS
Neurocognitive Disorders
Is the new category term for various forms of
dementia and amnestic disorders with major or
mild subtypes
In early editions of DSM they were called organic
mental disorders along with mood, anxiety,
personality, hallucinosis and delusional disorders.
The word organic indicated that brain damage or
dysfunction is involved. The organic mental
disorder category, however, covered so many
disorders that the distinction was meaningless.
The label cognitive disorders was used in DSM IV
to signify that their predominant feature is
impairment of such cognitive abilities such as
memory, attention, perception and thinking.
1. Delirium
Characterized by impaired consciousness and
cognition during the course of several hours or days
People with delirium appear confused, disoriented
and out of touch with their surroundings. They
cannot focus or sustain their attention on even the
simplest tasks. There are marked impairments in
memory and language.
It is most pervasive in older adults, people
undergoing medical procedures, cancer patients and
people with AIDS.
Delirium subsides relatively quickly.
Delirium may be experienced by children who have
high fevers and who are taking certain medications
and is often mistaken as non-compliance.
Sleep deprivation, excessive stress, and immobility
can also cause delirium,
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 2. Major and Mild Neurocognitive Disorders
Major Neurocognitive Disorder (previously labelled
dementia) is a gradual deterioration of brain
functioning that affects memory, language, and other
advanced cognitive processes.
Minor Neurocognitive Disorder is a new DSM V
disorder that was created to focus attention on early
stages of cognitive decline. Here the person has
modest impairments in cognitive functioning but can,
with some accommodation, continue to function
independently.
Causes of neurocognitive disorders include: several
medications, the abuse of drugs and alcohol,
infection or depression (but in these two its
reversible)
Agnosia: the inability to name and recognize objects
is one of the symptoms
Facial agnosia is the inability to recognize even
familiar faces can be extremely distressing to family
members.
DSM V identifies classes of neurocognitive disorders
based on etiology:
a) Alzheimers Disease
b) Vascular Injury
c) Fronto-temporal Degeneration
d) Traumatic Brain Injury
e) Lewy Body Disease
f) Parkinsons Disease
g) HIV infection
h) Subtance Use
i) Prion Disease
j) Another medical condition
3. Vascular Neurocognitive Disorders
8) A progressive brain disorder that is
commonly caused by tissue damage in the
brain because the blood vessels in the brain
are blocked or damaged.
Highlights of the Changes from DSM IV-TR to
DSM V
DSM-IVs organizational structure failed to reflect
shared features or symptoms of related disorders
and diagnostic groups (like psychotic disorders with
bipolar disorders, or internalizing (depressive,
anxiety, somatic) and externalizing (impulse control,
conduct, substance use) disorders.
DSM-5 restructuring better reflects these
interrelationships, within and across diagnostic
chapters
DSM-IV does not adequately address the lifespan
perspective, including variations of symptom
presentations across the developmental trajectory, or
cultural perspectives
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
DSM-5s chapter structure, criteria revisions,
and text outline actively address age and
development as part of diagnosis and
classification
Culture is similarly discussed more explicitly to
bring greater attention to cultural variations in
symptom presentations
DSM-5 represents an opportunity to better integrate
neuroscience and the wealth of findings from
neuroimaging, genetics, cognitive research, and the
like, that have emerged over the past several
decades all of which are vital to diagnosis and
treatment development
DSM-5 will be more amenable to updates in
psychiatry and neuroscience, making it a living
document and less susceptible to becoming
outdated than its predecessors
The multiaxial system in DSM-IV is not required to
make a mental disorder diagnosis and has not been
universally used
DSM-5 has moved to a nonaxial documentation
of diagnosis (formerly Axes I, II, and III), with
separate notations for important psychosocial
and contextual factors (formerly Axis IV) and
disability (formerly Axis V)
This approach is consistent with established
WHO and ICD guidance to consider the
individuals functional status separately from his
or her diagnoses or symptom status
Axis IV - psychosocial and environmental factors -
are now covered through an expanded set of V
codes. V codes allow clinicians to indicate other
conditions that may be a focus of clinical attention or
affect diagnosis, course, prognosis or treatment of a
mental disorder
Axis V - CGAS and GAF - are replaced by
separate measures of symptoms severity and
disability for individual disorders. An eventual
change to the World Health Organization
Disability Assessment Schedule (WHO DAS
2.0) is anticipated for measurement of disability,
however it is not yet recommended for use by
APA until it has been studied further.
Changes in Terminology
Not Otherwise Specified (NOS) has been used as a catch-all
for patients who didnt fit into the more specific categories.
NOS language is eliminated in DSM-5.
There will now be an option for designating Not Elsewhere
Classified (NEC) which will typically include a list of specifiers
as to why the patients clinical condition doesnt meet a more
specific disorder.
The phrase general medical condition is replaced in DSM-5
with another medical condition where relevant across all
disorders.
These classification changes will help providers with the
transition to ICD-10 in October 2014. DSM-5 includes the
ICD-10 diagnoses in parentheses.
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HIGHLIGHTS
1. Intellectual Disability (Intellectual Developmental
Disorder)
Diagnostic criteria for intellectual disability
(intellectual developmental disorder) emphasize
the need for an assessment of both cognitive
capacity (IQ) and adaptive functioning. Severity is
determined by adaptive functioning rather than IQ
score.
Despite the name change, the deficits in cognitive
capacity beginning in the developmental period,
with the accompanying diagnostic criteria, are
considered to constitute a mental disorder.
No longer use of term mental retardation.
2. Communication Disorders
The DSM-5 communication disorders include
new and revised conditions:
Language Disorder (which combines DSM-IV
expressive and mixed receptive-expressive
language disorders)
Speech Sound Disorder (a new name for
phonological disorder)
Childhood-Onset Fluency Disorder (a new
name for stuttering)
Social (pragmatic) Communication Disorder, a
new condition for persistent difficulties in the
social uses of verbal and nonverbal
communication (ASD is an obligate rule-out).
3. Autism Spectrum Disorder
Autism spectrum disorder is a new DSM-5 name
that reflects a scientific consensus that four
previously separate disorders are actually a
single condition with different levels of symptom
severity in two core domains.
ASD now encompasses the previous DSM-IV
autistic disorder (autism), Aspergers disorder,
childhood disintegrative disorder, and pervasive
developmental disorder not otherwise specified.
ASD is characterized by 1) deficits in social
communication and social interaction and 2)
restricted repetitive behaviors, interests, and
activities (RRBs). Because both components are
required for diagnosis of ASD, social
communication disorder is diagnosed if no RRBs
are present.
4. Attention Deficit Hyperactivity Disorder
Examples have been added to the criterion items
to facilitate application across the life span;
the cross-situational requirement has been
strengthened to several symptoms in each
setting;
the onset criterion has been changed from
symptoms that caused impairment were present
before age 7 years to several inattentive or
hyperactive-impulsive symptoms were present
prior to age 12
ADHD was placed in the neurodevelopmental
disorders chapter to reflect brain developmental
correlates with ADHD and the DSM-5 decision to
eliminate the DSM-IV chapter that includes all
diagnoses usually first made in infancy,
childhood, or adolescence.
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098
5. Schizophrenia subtypes
The DSM-IV subtypes of schizophrenia (i.e.,
paranoid, disorganized, catatonic,
undifferentiated, and residual types) are
eliminated due to their limited diagnostic stability,
low reliability, and poor validity.
6. Depressive Disorders
DSM-5 contains several new depressive
disorders, including disruptive mood
dysregulation disorder and premenstrual
dysphoric disorder.
To address concerns about potential
overdiagnosis and overtreatment of bipolar
disorder in children, a new diagnosis, disruptive
mood dysregulation disorder, is included for
children up to age 18 years who exhibit persistent
irritability and frequent episodes of extreme
behavioral dyscontrol.
What was referred to as dysthymia in DSM-IV
now falls under the category of persistent
depressive disorder, which includes both chronic
major depressive disorder and the previous
dysthymic disorder.
7. Bereavement Exclusion
In DSM-IV, there was an exclusion criterion for a
major depressive episode that was applied to
depressive symptoms lasting less than 2 months
following the death of a loved one (i.e., the
bereavement exclusion). This exclusion is
omitted in DSM-5 for several reasons.
The first is to remove the implication that
bereavement typically lasts only 2 months when
both physicians and grief counselors recognize
that the duration is more commonly 12 years.
Second, bereavement is recognized as a severe
psychosocial stressor that can precipitate a major
depressive episode in a vulnerable individual,
generally beginning soon after the loss.
Third, bereavement-related major depression is
most likely to occur in individuals with past
personal and family histories of major depressive
episodes.
8. Specifiers for Obsessive-Compulsive and
Related Disorders
The with poor insight specifier for obsessive-
compulsive disorder has been refined in DSM-
5 to allow a distinction between individuals with
good or fair insight, poor insight, and absent
insight/delusional obsessive-compulsive
disorder beliefs
9. Hoarding Disorder
Hoarding disorder is a new diagnosis in DSM-5.
10. Excoriation (Skin-Picking) Disorder
Excoriation (skin-picking) disorder is newly added
to DSM-5, with strong evidence for its diagnostic
validity and clinical utility.
11. Hypochondriasis and Illness Anxiety Disorder
Hypochondriasis has been eliminated as a
disorder, in part because the name was
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 perceived as pejorative and not conducive to an
effective therapeutic relationship.
Most individuals who would previously have been
diagnosed with hypochondriasis have significant
somatic symptoms in addition to their high health
anxiety, and would now receive a DSM-5
diagnosis of somatic symptom disorder.
In DSM-5, individuals with high health anxiety
without somatic symptoms would receive a
diagnosis of illness anxiety disorder (unless their
health anxiety was better explained by a primary
anxiety disorder, such as generalized anxiety
disorder).

12. Conversion Disorder (Functional Neurological

Symptom Disorder)
Criteria for conversion disorder (functional
neurological symptom disorder) are modified to
emphasize the essential importance of the
neurological examination, and in recognition that
relevant psychological factors may not be
demonstrable at the time of diagnosis

13. Avoidant/Restrictive Food Intake Disorder

DSM-IV feeding disorder of infancy or early
childhood has been renamed avoidant/restrictive
food intake disorder, and the criteria have been
significantly expanded.

14. Anorexia
The core diagnostic criteria for anorexia nervosa
are conceptually unchanged from DSM-IV with
one exception: the requirement for amenorrhea
has been eliminated.

15. Binge-Eating Disorder

Extensive research followed the promulgation of
preliminary criteria for binge eating disorder in
Appendix B of DSM-IV, and findings supported the
clinical utility and validity of binge-eating disorder.
The only significant difference from the preliminary
DSM-IV criteria is that the minimum average
frequency of binge eating required for diagnosis has
been changed from at least twice weekly for 6
months to at least

DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098 - 16