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In this module, a continuum of psychopathology is presented for your review. The diagnostic issues are supposedly arranged in order of severity. When you consider this continuum: 0 – Disorder Free Person 1 – Adjustment Disorder 2 – Anxiety Disorder 3- Personality Disorder: Mild to Moderate 4- Severe Personality Disorder 5 – Mood Disorder 6 – Dissociative Disorder 7- Psychosis what are the essential differences as you move up the scale? What are the implications for a) reality testing? , b) the quality of interpersonal relationships?, c) prognosis? Compare and contrast specific diagnoses of your choice in order to illustrate the contrasts in functioning that emerge here. What is the potential benefit of organizing psychopathology in this way and how might this continuum be useful? What are some legitimate criticisms that could be directed toward this conceptualization of psychopathology and what are the limitations of this framework in understanding psychopathology in general?
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This noslogy is an integration of several resources that are available as well as my own clinical experience. The objective, as with any nosology, is to cateogorize and classify a myriad of behaviors into a hierarchical continuum that will facilitate assessment and diagnosis. This will be the nosology we will use for this course. I have been influenced by Christopher Monte’s work here – I will incorporate and label sections from his chapter titled, “A Short Course in Psychopathology” which was within his seminal text titled Beneath the Mask (2008; Wiley and Son Publishers).
This is the continuum we will be evaluating and applying:
0 – Disorder Free Person
1 –
Adjustment Disorder
2 – Anxiety Disorder
3- Personality Disorder: Mild to Moderate
4- Severe Personality Disorder
5 –
Mood Disorder
6 – Dissociative Disorder
7- Psychosis
This continuum is created in order of severity of psychological or psychiatric symptoms. It is organized from the mildest to the most severe. I agree with Monte that the two most salient ways of understanding such a continuum are via reality testing (an ego function that enables one to differentiate between external reality and an inner imaginative world and to behave in a manner that exhibits an awareness of accepted norms and customs. Impairment of reality testing is indicative of a disturbance in ego functioning that may lead to psychosis. )and interpersonal relations or object relations.
Monte defines reality testing as follows (Monte, 2008, page 12):
“Reality testing can be defined as the person’s ability to distinguish
Monte defines interpersonal relationships as follows (Monte, 2008, page 12):
“Interpersonal relationships or object relations – as the psychoanalyst would prefer to call them – are an important indicator of the quality and stability of the person’s transactions with the social world. Interpersonal relationss can be mature, reciprocal, indpendent and caring, or they can be destructive, manipulative, conflicted and bizarre.”
Monte notes that these two functions are two salient severity markers in thinking about pathology. As pathology increases, reality testing decreases and the quality of interpersonal relationships decreases.
1- Adjustment Disorder
Monte writes: (Monte, 2008, page 13): “Disruptions to the person’s functioning that are triggered by an identifiable stressor in the recent past are classified as adjustment reactions…Interpersonal relationships usually undergo only momentary or transient changes.”
The following outline is based on adjustment disorders as defined by the DSM:
There are six major adjustment disorders:
· Adjustment disorder with depressed mood. A person with this type of adjustment disorder may mostly experience a depressed mood, hopeless feelings and crying spells.
· Adjustment disorder with anxiety. A person with this type of disorder experiences anxious feelings, nervousness and worry.
· Adjustment disorder with mixed anxiety and depressed mood. In these cases a person experiences a mixture of anxious and depressed feelings.
· Adjustment disorder with disturbance of conduct. A person with this disorder acts out inappropriately—against society, for example, or by skipping school or getting in trouble with the police.
· Adjustment disorder with mixed disturbance of emotions and conduct. A person with this disorder experiences a mixture of emotional and conduct problems.
· Adjustment disorder unspecified. In these cases a person’s symptoms are vague and undefined.
Diagnostic Criteria of DSM iv Adjustment Disorder
1. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s).
2. These symptoms or behaviors are clinically significant as evidenced by either of the following:
1. marked distress that is in excess of what would be expected from exposure to the stressor
2. significant impairment in social or occupational (academic) functioning
3. The stress-related disturbance does not meet the criteria for another specific Axis I disorder (clinical disorder) and is not merely an exacerbation of a preexisting Axis I or Axis II disorder (Personality Disorder or Mental Retardation).
4. The symptoms do not represent Bereavement.
5. Once the stressor (or its consequences) has terminated, the symptoms do not persist for more than an additional 6 months.
Specify if:
· Acute: if the disturbance lasts less than 6 months
· Chronic: if the disturbance lasts for 6 months or longer 慢性
Adjustment Disorders subtypes are selected according to the predominant symptoms:
· With Depressed Mood
· With Anxiety
· With Mixed Anxiety and Depressed Mood
· With Disturbance of Conduct
· With Mixed Disturbance of Emotions and Conduct
· Unspecified
2- Anxiety Disorders
Monte notes: (Monte, 2008, page 13-14): “The person suffering from this class of disorder may not be able to identify the source of the anxiety – as in the case of Generalized Anxiety Disorder – because several defense mechanisms are opertating to protect the person from self-awareness. Under such conditions, anxiety is termed free floating because the person does no experience it as anchored to a specific trigger idea or circumstance. From the afflicted person’s point of view, the distressing feelings of worry, fear and dread are a mystery. Reality testing is in tact; in fact, some theorists would argue that the individual is painfully attudned to reality. By contrast, some anxiety disorders have focused symptoms in which the anxiety is anchored to specifics. Phobias – which are unreasonable and unrealistic fears of places or things and obsessive-compulsive disorder in which the person may carry out undoing rituals or other magical cancellations to copoe with unwanted and persistent anxiety provoking thoughts. A particularly severe form of anxiety disorder, posttraumatic stress disorder, may build on other pathology already present. In some extreme cases, reality testing appears to fail (with PTSD) and it might call into question placing this disorder at this level”.
There are a number of anxiety disorders defined in the DSM IV-TR. They include: phobias, generalized anxiety disorder, panic attacks, obsessive compulsive disorder and post traumatic stress disorder.
These are the diagnositic criteria, via the DSM for anxiety disorders:
DSM-IV diagnostic criteria for 308.3 Acute Stress Disorder
1. The person has been exposed to a traumatic event in which both of the following were present:
1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others
2. the person’s response involved intense fear, helplessness or horror
2. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
1. a subjective sense of numbing, detachment, or absence of emotional responsiveness
2. a reduction in awareness of his or her surroundings
3. derealization
4. depersonalisation
5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
3. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
4. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
5. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).
6. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
7. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
8. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a pre-existing Axis I or Axis II disorder.
DSM-IV diagnostic criteria for 300.23 Social Phobia
1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
3. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
5. The avoidance, anxious anticipation, or distress in the feared social or performance situations(s) interferes significantly with the person’s normal routine, occupational functioning, or social activities or relationships, or there is marked distress about having the phobia.
6. In individuals under age 18 years, the duration is at least 6 months.
7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behaviour in Anorexia Nervosa or Bulimia Nervosa.
Specify if:
Generalized: if the fears include most social situations, also consider the additional diagnosis of Avoidant Personality Disorder.
DSM-IV diagnostic criteria for 300.02 Generalised Anxiety Disorder
1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
2. The person finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued
3. Difficulty concentrating
or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder) being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
6. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
DSM-IV criteria for Panic Attack
A discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms developed abruptly and reached a peak within ten minutes.
1. Palpitations, pounding heart or accelerated heart rate.
2. Sweating
3. Trembling or shaking
4. Sensations of shortness of breath or smothering.
5. Feeling of choking
6. Chest pain or discomfort
7. Nausea or abdominal distress
8. Feeling dizzy, unsteady, light headed or faint.
9. Derealisation(feelings of unreality) or depersonalisation (being detached from oneself)
10. Fear of losing control or going crazy.
11. Fear of dying
12. Paresthesias (numbness or tingling sensations)
13. Chills or hot flushes.
DSM-IV criteria for 300.29 Specific phobias
1. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g. flying, heights, animals, receiving an injection, seeing blood)
2. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally pre disposed panic attack. Note: in children, the anxiety may be expressed by crying, tantrums, freezing or clinging.
3. The person recognises that the fear is excessive and unreasonable. Note: in children this feature may be absent.
4. The phobic situation is avoided or is endured with intense anxiety or distress.
5. The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with a person’s routine, occupational (or academic) functioning, or social activities or relationships or there is a marked distress about having the phobia.
6. In individuals under the age of 18 years the duration is at least 6 months.
7. The anxiety panic attacks or phobic avoidance associated with the specific object or situation are not better accounted for by another mental disorder such as OCD (e.g. fear of dirt in someone with an obsession about contamination), post traumatic stress disorder (e.g. avoidance of school), social phobia, panic disorder with agoraphobia or agoraphobia without history of panic disorder).
DSM diagnostic criteria for 300.3 Obsessive Compulsive Disorder
1. Either obsessions or compulsions: Obsessions as defined by 1,2, 3 and 4;
1. Recurrent and persistent thoughts, impulses or images that are experienced at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
2. The thoughts, impulses or images are not simply excessive worries about real life problems.
3. The person attempts to ignore or suppress such thoughts, impulses or images or to neutralise them with some other thought or action.
4. The person recognises that the obsessional thoughts, impulses or images are a product of his or her own mind (not imposed from without as with thought insertion).
Compulsions are defined as 1 and 2
5. Repetitive behaviours (e.g. hand washing, ordering checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly.
6. The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive.
2. At some points during the course of the disorder, the person has recognised that the obsessions or compulsions are excessive or unreasonable. Note: this does not apply to children.
3. The obsessions and compulsions cause marked distress, are time consuming (take more than one hour a day), or significantly interfere with the persons normal routine, occupational (or academic) functioning, or usual social activities or relationships.
4. If another axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g. preoccupation with food in the presence of an eating disorder, hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder: preoccupation with drugs in the presence of a Substance use disorder : preoccupation with having a serious illness in the presence of hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia: or guilty ruminations in the presence or major depressive Disorder.
5. The disturbance is not due to the direct physiological effects of a substance (e.g. drug of abuse, a medication) or a general medical condition.
Specify if with poor insight: If, for most of the time during the current episode, the person does not recognise that the obsessions and compulsions are excessive or unreasonable.
Although people have very different abilities to endure stress, it seems likely that everyone has a breaking point if exposed for long enough to an extreme enough stressor. Once Posttraumatic Stress Disorder occurs, its symptom pattern is remarkably uniform regardless of the individual’s previous psychological history or cultural background. However different a person is before developing Posttraumatic Stress Disorder, there is a very human pattern of response to an extreme stressor that includes avoidance of stimuli that remind the person of the stressor, re-experiencing the stressor in a number of ways, and increased physiological arousal, particularly on exposure to memory jogging triggers.
DSM diagnostic criteria for 309.81 Post Traumatic Stress Disorder
1. The person has been exposed to a traumatic event in which both of the following were present:
1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.
2. The person’s response involved intense fear, helplessness, or horror. NOTE: in children, this may be expressed instead by disorganised or agitated behaviour.
2. The traumatic event is persistently re experienced in one (or more) of the following ways.
1. Recurrent and intrusive distressing recollections of the event including images thoughts or perceptions. Note: In young children repetitive play may occur in which themes or aspects of the trauma are expressed.
2. Recurrent distressing dreams of the event. Note: in children, there may be frightening dreams without recognisable content.
3. Acting or feeling as if the traumatic event were recurring (includes a sense of relieving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: in children, trauma specific re-enactment may occur.
4. Intense psychological distress at exposure to the internal or external cues that symbolise or resemble an aspect of the traumatic event.
3. Persistant avoidance of stimuli associated with the trauma and the numbing of general responsiveness (not present before trauma), as indicated by three or more of the following:
1. Efforts to avoid thoughts, feelings or conversations associated with the trauma.
2. Efforts to avoid the activities, places or people that arouse recollections of the trauma.
3. Inability to recall important aspect of the trauma.
4. Markedly diminished interest or participation in significant activities.
5. Feelings of detachment or estrangement from others.
6. Restricted range of affect (e.g. unable to have loving feelings).
7. Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life span).
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hyper vigilance
5. Exaggerated startle response
5. Duration of the disturbance (symptoms in criteria B, C and D) is more than one month.
6. The disturbance causes clinically significant distress or impairment in social occupational, or other important areas of functioning.
Specify if:
Acute: if duration of symptoms is less than three months.
Chronic: if duration of symptoms is three months or more.
Specify if with delayed onset: If onset of symptoms is at least 6 months after the stressor.
DSM-IV diagnostic criteria for 293.89 Anxiety Disorder due to general medical condition
1. Prominent anxiety, panic attacks, or obsessions or compulsions predominate in the clinical picture.
2. There is evidence from the history, physical examination or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
3. The disturbance is not better accounted for by another mental disorder (e.g. Adjustment Disorder with anxiety in which the stressor is a serious general medical condition).
4. The disturbance does not occur exclusively during the course of the delirium.
5. The disturbance causes clinically significant distress or impairment in social occupational, or other important areas of functioning.
Specify if:
· With generalized anxiety: if excessive anxiety or worry about a number of events or activities predominates in the clinical presentation.
· With panic attacks: if the panic attacks predominate in the clinical presentation.
· With Obsessive Compulsive symptoms: If obsessions or compulsions predominate in the clinical presentation.
DSM-IV criteria for Agoraphobia
Agoraphobia is not a codable disorder. Code the specific disorder in which the Agoraphobia occurs (e.g. 300.21 Panic Disorder with Agoraphobia or 300.22 Agoraphobia without history of panic disorder).
1. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic like symptoms. Agoraphobia fears typically involve characteristic clusters of situations that include being outside the home alone: being in a crowd or standing in a line; being on a bridge: and traveling in a bus, train, or automobile. Note: consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations or Social Phobia if the avoidance is limited to social situations.
2. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic like symptoms, or require the presence of a companion.
3. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia (e.g. avoidance limited to social situations because of fear of embarrassment), Specific phobia (avoidance limited to a single situation like elevators), Obsessive Compulsive Disorder (e.g. avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g. Avoidance of stimuli associated with a severe stressor) or Separation Anxiety Disorder (e.g.avoidance of leaving home or relatives).
DSM-IV diagnostic criteria for 300.22 Agoraphobia without history of Panic Disorder
1. The presence of Agoraphobia related to fear of developing panic- like symptoms (e.g. dizziness or diarrhea).
2. Criteria have never been met for Panic Disorder.
3. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or general medical condition.
4. If an associated general medical condition is present, the fear described in criterion A is clearly in excess of that usually associated with the condition.
Summary of DSM-IV diagnostic criteria for 300.01 Panic Disorder without Agoraphobia and 300.21 Panic Disorder with Agoraphobia
1. Both (1) and (2)
1. Recurrent unexpected Panic Attacks
2. At least one of the attacks has been followed by at least a month of the following:
1. Persistent concern about having additional attacks
2. Worry about the implications of the attack or its consequences (e.g losing control, having a heart attack, or going crazy)
3. A significant change in behavior related to the attacks
2. This criterion differs for Panic Disorder with and without Agoraphobia as follows: For 300.21 Panic Disorder with agoraphobia: the presence of Agoraphobia. For 300.01 Panic Disorder without Agoraphobia: absence of Agoraphobia.
3. The Panic Attacks are not due to the direct physiological effects of a substance (e.g. a drug of abuse, medication) or a general medical condition (e.g. hyperthyroidism).
4. The Panic Attacks are not better accounted for by another mental disorder, such as Social phobia (e.g. occurring on exposure to feared social situations), Specific Phobia, (e.g. on exposure to phobic situation), Obsessive Compulsive Disorder (e.g. on exposure to dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder, (e.g. in response to stimuli associated with a severe stressor), or separation Anxiety Disorder (e.g. in response to being away from home and close relatives).
DSM-IV text for 300.00 Anxiety Disorder not otherwise specified
This category includes disorders with prominent anxiety or phobic avoidance that do not meet criteria for any specific Anxiety Disorder, Adjustment Disorder with Anxiety, or Adjustment Disorder with mixed Anxiety and depressed mood. Examples include:
1. Mixed anxiety-depressive disorder: clinically significant symptoms of anxiety and depression, but the criteria are not met for either a specific Mood Disorder or a specific Anxiety Disorder.
2. Clinically significant social phobic symptoms that are related to the social impact of having a general medical condition or mental disorder (e.g. Parkinson’s disease, dermatological conditions, Stuttering, Anorexia Nervosa, Body Dysmorphic Disorder).
3. Situations in which the clinician has concluded that an Anxiety Disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
3 and 4- Personality Disorders
Monte writes, (Monte, 2008, page 15-16): “Marked by the presence of troublesome and long standing character traits, personality disorders put the person into conflict with the social environment. A long developmental history, sometimes dating from childhood, is almost by definition a requirement for the emergence of these disorders…As you might suspect, personality disorders embody substantial, pervasive and persistent difficulties in interpersonal relationships. People with personality disorders may treat other people manipulatively, aggressively, selfishly or indifferently.”
With personality disorders, the DSM offers these general guidelines before diagnosing:
A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)
(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).
Here are the personality disorders:
Mild Classification: Anxious or Fearful Disorders (sometimes referred to as Cluster C in the psychological literature)
Avoidant personality disorder
Dependent personality disorder
Obsessive-Compulsive personality disorder
Moderate to Severe Classification: Odd or Eccentric Disorders (sometimes referred to as Cluster A in the psychological literature):
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Also Moderate to Severe Classification: Dramatic, Emotional or Erratic Disorders (sometimes referred to as Cluster B disorders in the psychological literature):
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
5 – Mood Disorders
Monte writes regarding mood disorders, (Monte, 2008, page 18): “There are extreme disruptions to reality testing and interpersonal relationships evidenced by people with these disorders…reality testing can fail, withdrawal from social contact can occur and suicidal thoughts are frequently observed.”
Here are the DSM IV-TR criteria for mood disorders:
Criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either
(1) depressed mood or
(2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood ingruent delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) Insomnia or Hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
B. The symptoms do not meet criteria for a Mixed Episode (see p. 335).
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
Bipolar Disorder:
3. Bipolar Episode and Bipolar Disorder
Bipolar disorder is characterized by more than one bipolar episode. There are three types of bipolar disorder:
1. Bipolar 1 Disorder, in which the primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression.
2. Bipolar 2 Disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalization, but are sufficient to be observable by others).
3. Cyclothymic Disorder, a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder (APA 2000, pp. 388–392).
Manic episodes are characterized by:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (4 if the mood is only irritable) and have been present to a significant degree:
(1)increased self-esteem or grandiosity
(2)decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3)more talkative than usual or pressure to keep talking
(4)flight of ideas or subjective experience that thoughts are racing
(5)distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6)increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
(7)excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)” (
APA, 2000
, p. 362).
There is also a less severe form of depression, known as dysthymia which we can consider at this point as well:
Diagnostic criteria for 300.4 Dysthymic Disorder
A. Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
(1) poor appetite or overeating
(2) Insomnia or Hypersomnia
(3) low energy or fatigue
(4) low self-esteem
(5) poor concentration or difficulty making decisions
(6) feelings of hopelessness
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. No Major Depressive Disorder has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
Note: There may have been a previous Major Depressive Episode provided there was a full remission (no significant signs or symptoms for 2 months) before development of the Dysthymic Disorder. In addition, after the initial 2 years (1 year in children or adolescents) of Dysthymic Disorder, there may be superimposed episodes of Major Depressive Disorder, in which case both diagnoses may be given when the criteria are met for a Major Depressive Episode.
E. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode, and criteria have never been met for Cyclothymic Disorder.
F. The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
G. The symptoms are not due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
Early Onset: if onset is before age 21 years
Late Onset: if onset is age 21 years or older
6 – Dissociative Disorders
Diagnostic criteria for 300.6 Depersonalization Disorder
A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalization experience, reality testing remains intact.
C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy)
Diagnostic criteria for 300.14 Dissociative Identity Disorder
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person’s behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
7- Psychosis
Monte writes, (2008, page 18): “The most severe of the psychiatric illnesses, the psychoses are devastating assaults on a person’s ability to think clearly and to experience feelings normally. The schizophrenic person loses touch with reality, may experience hallucinations and may have delusional beliefs and other problems in thinking. Reality testing is therefore grossly defective. The coherence of thinking and speech is disrupted to different degrees depending on the severity and type of schizophrenia…Interpersonal relationships are totally disrupted or completely devoid of intimacy in any meaningful sense of a personal relationship”.
The following is a summary of diagnostic criteria from the DSM IV-TR for schizophrenia:
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A. Characteristic Symptoms:
Two (or more) of the following, each present for a significant portion of time during a 1-month
period:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms, i.e., affective flattening, alogia, or avolition
B. Social / Occupational Dysfunction:
For a significant portion of the time since the onset of the disturbance, one or more major areas of
functioning such as work, interpersonal relations, or self-care are markedly below the level
achieved prior to the onset.
C. Duration:
Continuous signs of the disturbance persist for at least 6 months. This 6-month period must
include at least 1 month of symptoms that meet Criterion A and may include periods of prodromal
or residual symptoms.
D. Schizoaffective and Mood Disorder Exclusion:
Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out
because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently
with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to the duration of the active and residual
periods.
E. Substance / General Medical Condition Exclusion:
The disturbance is not due to the direct physiological effects of a substance or a general medical
condition.
F. Relationship to a Pervasive Developmental Disorder:
If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the
additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month.
Schizophrenia Sub-Types
Diagnostic Criteria for 295.30 Paranoid Type:
are met:
A type of Schizophrenia in which the following criteria
A
. Preoccupation with one or more delusions or frequent auditory hallucinations.
B
catatonic behavior, or flat or inappropriate affect.
. None of the following are prominent: disorganized speech, disorganized or
Diagnostic Criteria for 295.10 Disorganized Type:
criteria are met:
A type of Schizophrenia in which the following
A.
1. Disorganized speech
2. Disorganized behavior
3. Flat or inappropriate affect
All of the following are prominent:
B.
The criteria are not met for Catatonic Type.
Diagnostic Criteria for 295.90 Undifferentiated Type:
A type of Schizophrenia in which symptoms thatmeet Criterion A are present, but the criteria are not met for the Paranoid, Disorganized, or Catatonic Type.
Last modified: Sunday, October 23, 2011, 7:27 PM
Chapter 22:
Global Assessment of Functioning (GAF) Scale
BY LYNN GEURIN, MSW, CSW
Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations.
Code (Note: Use intermediate codes when appropriate, e.g., 45, 68, 72.)
|
1 0 0 |
Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms. |
|
90 |
Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). |
|
80 |
If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). |
|
70 |
Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. |
|
60 |
Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). |
|
50 |
Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). |
|
40 |
Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). |
|
30 |
Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends) |
|
20 |
Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). |
|
10 |
Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death. |
| 0 |
Inadequate information. |
LYNN GEURIN, MSW, CSW
Pathways, Inc.
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Kentucky Dept. of Public Advocacy
http://www.dpa.state.ky.us
